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Gynecology 


MEDICAL  AND  SURGICAL 


S.  POZZI,  M.D. 

Professeur  Agrege  a  la  Faculte  de  Medecine  ;  Cbirurgien  de  l'Hopital  Lourcine-Pascal, 
Paris  ;  Honorary  Fellow  of  the  American  Gynaecological  Society. 


Translated  from  the  French  Edition  under  the  Supervision  of, 
and  with  Additions  by 

BROOKS    H.  WELLS,   M.D. 

Lecturer  on  Gynaecology  at  the  New  York  Polyclinic ;  Fellow  of  the  New  York  Obstetrical 
Society,  and  the  New  York  Academy  of  Medicine. 


VOLUME   ONE 
With  305  Wood  Engravings  and  6  Full-page  Plates  in  Color 


NEW  YORK 

WILLIAM   WOOD   &   COMPANY 

1891 


Copyrighted,  iSgi 
WILLIAM  WOOD  &  COMPANY 


ELECTROTYPED   AND    PRINTED    BY 

THE   PUBLISHERS'    PRINTING   COMPANY 

30    4   32    WEST    13TH    STREET 

NEW   YORK 


AUTHOR'S   PEEFACE   TO   FRENCH  EDITION. 


This  work  is  the  result  of  several  years  of  practical  experience 
as  chief  of  a  hospital  service  at  Lourcine,  devoted  especially  to  the 
diseases  of  women.  The  materials  for  the  works  published  by 
Huguier,  Bernutz  and  Goupil,  Alph.  Guerin.  De  Martineau,  and  their 
pupils  were  gathered  from  the  same  field.  Thanks  to  the  increased 
facilities  offered  in  gynaecological  surgery  by  the  addition  of  the  Pas- 
cal Annex,  I  have  for  six  years  been  able  to  give  regular  gynaecological 
instruction.  Moreover,  the  kindness  of  the  dean,  M.  Brouardel,  has 
permitted  me  to  conduct  a  free  supplementary  course  of  gynaecology 
at  the  Faculte  de  Medecine.  The  lessons  there  given  have  served  as  an 
outline  in  the  compilation  of  this  book.  Furthermore,  I  have,  in  the 
course  of  several  journeys  abroad,  studied  the  methods  of  the  princi- 
pal gynaecologists  of  England,  Germany,  and  Austria,  and  compared 
their  instructions  with  those  of  the  Faculte  of  Paris,  where  my  own 
studies  Avere  pursued. 

It  is  impossible  to  ignore  the  great  prominence  which  gynaecology 
has  everywhere  assumed.  The  origin  of  its  rapid  progress  is  easy  to 
trace.  By  the  introduction  of  antisepsis  a  new  era  was  opened  to 
gynaecology  as  well  as  to  general  surgery.  Active  intervention  has 
become  almost  free  from  danger  in  many  diseases  which  used  to  be 
abandoned  to  palliative  or  disguised  expectant  treatment.  Thanks 
to  antisepsis,  new  operations  have  been  invented,  and  old  ones  re- 
stored to  favor.  Some  of  the  latter  had  been  boldly  conceived  and 
brilliantly  performed  by  our  predecessors,  but  the  terrific  mortality 
due  to  surgical  uncleanliness  had  caused  their  abandonment.  Such 
was  the  case  with  ovariotomy,  vaginal  hysterectomy,  curetting,  and 
even  shortening  the  round  ligaments ;  their  present  use  is  merely  a 
revival. 

Previous  to  Pasteur's  great  discovery,  rendered  fruitful  by  Lister, 
boldness  in  operative  medicine  was  sheer  temerity.  If  an  occasional 
success  raised  hopes,  they  were  at  once  destroyed  by  a  series  of  mis 
haps.     In  1822  Sauter  (of  Constance)  obtained  the  first  successful 


IV  AUTHOR  S  PREFACE  TO  FRENCH  EDITION. 

result  in  vaginal  hysterectomy  for  the  cure  of  cancer.  After  this  one 
isolated  cure,  eleven  consecutive  deaths  followed  the  first  eleven 
operations  performed  in  imitation  of  his,  and  in  all  probability  a 
complete  list  of  the  victims  has  never  been  published.  Scarcely 
twenty  years  ago,  surgery  had  fallen  into  discouragement  and  had 
renounced  all  active  measures  in  a  great  part  of  the  gynaecological 
field.  Accidents  during  labor  or  the  consequences  of  labor  were  left 
in  the  hands  of  accoucheurs,  and  the  numerous  forms  of  metritis, 
nearly  all  displacements,  and  reflex  nervous  disorders,  perimetritic 
inflammations,  etc.,  to  the  general  practitioner.  Thus  dismembered 
and  parcelled  out  among  surgeons,  general  physicians,  and  obstetri- 
cians, gynaecology  was  far  from  forming  the  definite  and  distinct  branch 
of  the  healing  art  that  it  does  at  the  present  day.  Not  so  very  long 
ago  a  good  operator  was  a  good  surgeon,  the  two  terms  being  almost 
synonymous.  This  is  no  longer  the  case.  It  has  become  of  even  more 
importance  to  avoid  infection  of  the  wound  than  to  operate  brilliantly. 

Antisepsis  has  now  triumphantly  overcome  all  opposition;  all  our 
instructors  teach  it,  and  the  younger  generation  practise  it  with  the 
fervor  inspired  by  new  religions.  We  are  as  well  armed  for  the  strife 
as  our  neighbors.  Let  us  profit  by  their  experience,  and  avoid  the 
operative  excesses  into  which  they  have  too  often  fallen. 

In  view  of  these  tendencies,  which,  it  is  to  be  feared,  have  sometimes 
caused  the  sacrifice  of  a  careful  clinical  study  of  the  disease,  and  a 
patient  and  exact  determination  of  the  diagnosis  and  prognosis  to  the 
eclat  of  immediate  results,  it  seems  to  me  that  a  definite  role  falls 
naturally  to  the  lot  of  French  gynaecology.  Let  it  accept  without 
qualification  the  bold  and  useful  inventions  of  foreign  origin,  but  let 
it  exercise  a  more  solicitous  surveillance  over  wjiat  is  in  reality  the 
highest  part  of  our  art,  an  exact  interpretation  of  indications.  There 
will  then  be  no  missing  link  in  the  chain  of  its  records,  and  its  future 
will  be  worthy  of  its  glorious  past. 

This  past  is  too  little  remembered  at  the  present  day.  We  our- 
selves are  not  proud  enough  of  our  long  scientific  lineage,  which 
made  us  the  teachers  of  other  nations,  in  gynaecology  as  well  as  in  all 
the  other  branches  of  the  healing  art.  This  is  an  opportune  moment 
to  recall  it  to  the  memory  of  those  among  us  who  choose  to  neglect 
our  works,  and  who  were  quick  to  announce  our  decline  at  a  time 
our  activity  were  temporarily  retarded.  Are  not  modern  methods  of 
exploration,,  operations  in  use  at  the  present  day,  new  departures  in 
gynaecological  nosology  largely  of  French  origin?    Bimanual  explora- 


AUTHOR'S    PREFACE   TO    FRENCH    EDITION.  V 

tion,  which  has  been  said  to  be  a  more  valuable  aid  to  investigation 
than  even  the  speculum,  was  introduced  in  France  by  Puzos  in  1753, 
and  adopted  by  Levret  and  Baudelocque  long  before  Kiwisch,  Veit, 
and  Schultze  revived  its  use.  The  speculum,  forgotten  since  the  days 
of  antiquity,  of  Soranus  and  Paul  of  iEginus,  hrst  reappears  i»  the 
works  of  Ambroise  Pare,  the  illustrious  Father  of  French  Surgery, 
then  in  the  surgical  armamentarium  published  by  Cullet,  and  finally 
assumes  definite  importance  in  the  hands  of  Recamier,  physician  of 
1'Hotel-DieUj  who  introduced  it  into  general  use.  Neither  Lair  nor 
Simpson  nor  Kiwisch  were  the  ones*  to  discover  the  diagnostic  value 
of  measuring  the  uterus  with  the  uterine  sound;  the  great  French 
obstetrician  Levret,  in  1771,  was  the  discoverer,  and  Huguier,  the 
eminent  surgeon  of  Lourcine,  was  the  one  who,  after  rescuing  hyster- 
ometry  from  the  discredit  into  which  it  had  fallen,  formulated  the 
indications  for  its  use. 

Shall  I  speak  of  operations?  Curetting  was  invented  by  a  French- 
man, Recamier;  the  operation  for  vesico-vaginal  fistula  was  first 
scientifically  established  and  successfully  used,  in  a  hitherto  unknown 
degree,  by  a  Frenchman,  Jobert  de  Lamballe.  The  surgeons  who  first 
attacked  polypi,  either  by  ligature  (Levret)  or  boldly  with  a  cutting 
instrument  (Dupuytren)  were  French.  The  one  who  first  had  the 
daring  to  enucleate  fibromata  in  the  uterine  tissue  (Amussat)  was 
French.  In  France,  Recamier  performed,  if  not  the  first,  at  least  the 
second,  successful  vaginal  hysterectomy  for  cancer.  It  was  in  France 
(in  Strasburg),  that  our  eminent  compatriot  Kceberle  was  one  of  the 
first  who  of  deliberate  purpose  (and  not  accidentally,  like  the  greater 
number  of  his  predecessors)  opened  the  abdomen  to  remove  an  in- 
terstitial uterine  fibroid.  It  was  in  Paris  that  Pean  established  a 
plan  of  technique  for  abdominal  hysterectomy  which  was  classical 
for  many  years. 

If  we  pass  to  nosology,  to  the  anatomico-pathological  and  clinical 
study  of  diseases,  here  again  we  meet  a  crowd  of  French  leaders,  and 
we  have  only  an  embarras  de  clioix :  Huguier  for  diseases  of  the  ex- 
ternal genitals  and  supravaginal  hypertrophic  elongation-  of  the  cer- 
vix; Nelaton  for  retro-uterine  hematocele;  Valleix,  Aran,  Bernutz 
and  Goupil,  Gallard,  Alphonse  Gruerin,  for  peri-  and  parametric  inflam- 
mations ;  Malassez  and  De  Sinety,  Cornil  for  the  pathological  anatomy 
of  ovarian  cysts,  endometritis,  etc. 

I  will  pause  here  lest  this  legitimate  reclamation  become  a  pane- 
gyric.    I  merely  wished  to  show  that  our  patriotism  has  every  cause 


vi  authok's  peeface  to  feench  edition. 

to  be  at  ease  on  questions  of  bibliography,  and  that  when  we  quote 
from  a  foreign  author  we  often  do  no  more  than  to  take  back  our  o\tu 
capital  with  the  accumulated  interest  thereon. 

I  have  largely  consulted  foreign  publications,  and  have  quoted  as 
many  English,  American,  and  German  as  French  names.  It  is  possi- 
ble that  I  may  be  criticised  for  so  doing,  but  "  For  whoever  thinks, 
there  is  neither  French  nor  English,"  said  Voltaire. 

My  endeavor  has  been  as  far  as  possible  to  present  an  exact  state- 
ment of  the  present  condition  of  science  in  all  countries,  without  giv- 
ing a  cumbersome  mass  of  detail.  For  that  reason  I  have  abstained 
from  dwelling  at  any  length  upon  historical  data  preceding  the  anti- 
septic period,  although  I  have  not  neglected  any  occasion  to  assert 
any  just  claims  of  priority  upon  the  part  of  operators,  without  regard 
to  nationality. 

In  respect  to  bibliography,  I  have  thought  it  best  not  to  make  ex- 
haustive extracts  from  the  enormous  mass  of  documents  which  I 
could  easily  have  reached  through  special  indexes — Reime  des  Sci- 
ences Medicales,  Index  Catalogue,  Index  medicus,  Centralblatt,  etc. 
This  cheap  form  of  erudition  seems  to  me  of  more  ostentatious  value 
to  the  compiler  than  of  real  use  to  the  reader.  Those  desirous  of 
pursuing  the  subject  farther  can  have  ready  access  to  these  publica- 
tions. There  was  a  time  (not  so  very  remote)  when  a  complete  biblio- 
graphy was  essential  to  the  comrnling  of  any  book.  That  time  is 
past.  At  the  present  day  we  are  obliged  to  be  incomplete,  in  view  of 
the  enormous  and  constant  accumulation  of  literary  matter  upon 
medical  topics.  It  is  better  to  frankly  acknowledge  this  inevitable 
necessity,  and  make  a  choice  of  what  we  consider  worthy  of  quota- 
tion. For  my  part, 'I  have  limited  myself  to  advising  a  consultation, 
upon  each  subject,  of  the  most  recent  and  best  works  that  I  had  been 
able  to  find.  I  have  given  the  fullest  list  of  references  in  regard  to 
the  questions  which  excite  the  most  interest  at  the  present  day,  or 
about  which  there  is  the  most  dispute  (Battey's  operation,  hystero- 
pexy, etc.).  I  have  made  very  few  quotations  at  second  hand,  and 
those  I  have  been  careful  to  verify. 

In  a  book  designed  for  instruction,  the  author  is  always  placed  be- 
tween two  horns  of  a  dilemma.  Either  he  is  in  danger  of  sacrificing 
everything  to  perspicuity,  dwelling  upon  outlines  and  leaving  in  the 
shade  many  details  which  might  interfere  with  the  schematic  clear- 
ness of  his  sketch,  in  which  case  he  is  in  danger  of  being  incomplete 
and  sometimes  artificial;  or  else  he  tries  to  omit  nothing  from  his 


author's  peeface  to  French  edition.  yjl 

picture,  even  though  the  addition  of  details  and  matter  of  secondary 
importance  takes  something  from  the  prominence  of  the  chief  topics ; 
he  runs  the  risk  in  this  case  of  being  heavy  and  diffuse. 

I  have  constantly  endeavored  to  steer  clear  of  this  double  danger, 
and,  although  I  cannot  claim  entire  success,  yet  I  can  claim  to  have 
done  my  best  to  that  end.  I  deemed  it  essential  to  dwell  at  length 
upon  the  more  recent  gynaecological  orjerations,  which  were  often  in- 
completely reported  by  my  French  predecessors,  and  somewhat  ob- 
scurely described  in  the  many  existing  translations  of  foreign  works. 
On  the  other  hand,  it  seemed  unnecessary  to  give  a  detailed  anatomi- 
cal description  of  the  female  genital  organs ;  I  contented  myself  with 
a  few  indispensable  general  indications  quite  sufficient  for  a  work 
on  pathology.  The  only  details  entered  into  are  in  reference  to  the 
external  organs  of  generation,  where  certain  views  had  to  be  stated, 
in  regard  to  their  development  and  homology,  which  seemed  to  me  to 
throw  light  upon  the  origin  of  some  interesting  malformations. 

Many  of  my  illustrations  are  original;  they  were  drawn  under  my 
direction  by  M.  Nicolet,  who  is  both  skilful  and  intelligent.  I  have 
also  borrowed  largely  from  various  treatises  and  monographs.  In  every 
case  where  these  illustrations  had  any  originality,  I  acknowledged 
their  source,  omitting  this  formality  only  in  the  case  of  those  which 
came  from  classical  works  known  by  every  one,  and  which  have  been 
so  often  reproduced  as  to  be  almost  public  property. 

Professor  Cornil  kindly  gave  me  permission  to  reproduce  the  re- 
markable histological  illustrations  of  his  lessons  on  endometritis,  can- 
cer, salpingitis,  and  genital  tuberculosis.  Professor  Wyder  was  good 
enough  to  allow  me  to  make  reduced  copies  of  the  valuable  plates  in 
his  atlas.  M.  Toupet,  with  his  well-known  ability  and  courtesy,  made 
several  anatomical  examinations  for  me,  relative  to  salpingitis  and 
follicular  ovarian  cysts.  A  few  illustrations  were  kindly  lent  by  MM. 
L.  le  Fort,  Tarnier,  Doleris,  Dumoret,  Marcel  Baudouin,  Poirier, 
Laroyenne,  Collin,  Mathieu,  Aubry,  Eaynal,  Dupont. 

My  good  friend  Professor  Testut  and  my  brother,  Dr.  xidrien 
Pozzi  (of  Rheims),  deserve  my  gratitude,  the  one  for  making  out  the 
indexes,  the  other  for  correcting  the  proofs. 

Finally,  I  wish  to  thank  the  publisher,  my  friend  M.  Georges  Mas- 
son,  whose  faithful  co-operation  has  greatly  facilitated  the  execution 
of  my  laborious  undertaking. 

Paris,  July  22d,  1890. 


EDITOR'S    PREFACE. 


The  treatise  here  given  to  English  readers  is  undoubtedly  the  best 
work  on  gynaecology  which  has  appeared  for  many  years  in  any  lan- 
guage. The  cosmopolitan  spirit  of  its  author,  shown  in  his  exhaustive 
research  and  judicious  appreciation  of  the  work  of  other  nations, 
together  with  his  keen  and  mature  judgment  in  utilizing  the  material 
from  his  own  rich  clinical  fields,  make  it  a  clear  and  reliable  guide  to 
the  most  advanced  and  best  practice  in  this  specialty.  • 

But  few  changes  have  been  made  or  thought  necessary,  the  en- 
deavor having  been  to  follow  the  original  as  closely  as  possible.  A 
number  of  editorial  notes  have  been  added.  They  refer  mainly  to 
minor  points  and  have  been  enclosed  in  brackets.  Certain  cuts  of 
specula,  complicated  examination  tables,  and  pessaries  have  been 
omitted  or  replaced  by  others,  and  a  few  new  illustrations  have  been 
added.  Six  full-page  colored  lithographic  plates  have  been  inserted 
in  the  first  volume  and  nine  in  the  second.  These  illustrate  important 
portions  of  the  text;  some  of  them  are  new  and  some  are  taken  from 
the  American  Journal  of  Obstetrics.  The  voluminous  bibliographi- 
cal notes  which  enrich  the  work  have  been  transferred  from  their 
original  position,  at  the  foot  of  each  page,  to  the  end  of  each  chapter 
— an  arrangement  which  improves  the  appearance  of  the  work  and 
is  equally  convenient  for  reference.  I  am  indebted  to  Drs.  Aimee 
Raymond  and  Alfred  E.  Thayer,  of  this  city,  for  assistance  in  the 
translation,  and  in  the  preparation  of  the  index. 

B.  H.  W. 

71  "West  45th  Street,  January  1st,  1892. 


TABLE   OF   CONTENTS. 
VOLUME   I. 


ANTISEPSIS.      ANAESTHESIA.      CONTROL  OF  HEMORRHAGE  AND 

CLOSURE    OF   WOUNDS.     DRAINS    AND   TAMPONS. 

EXAMINATION    OF    THE    PATIENT. 

CHAPTER  I. 

Antisepsis  in  Gynaecology. 

PAGE 

Antisepsis  and  Asepsis  in  Operations  by  the  Natural  Passages  :  a,  of  the 
.Operator ;  &,  of  the  Instruments  ;  c,  of  the  Operating-Rooin  and  its 
Furniture  ;  d,  of  the  Patient. — Antisepsis  of  the  External  Genitals. — 
Sublimate  Solution,  its  Disinfectant  and  Toxic  Powers. — Acidulated 
Sublimate  Solution. — Creolin. — Beta-naphthol. — Vaginal  Injections. — 
Injections  Before  and  During  the  Operation. — Deodorizing  Injections. — 
Rectal  and  Vesical  Injections. — Iodoform,  Sublimate,  Salol,  Iodol,  and 
Carbolic  Gauze. — Antisepsis  of  the  Cervix. — Iodoform  Crayons. — Lam- 
inaria. — Antisepsis  of  the  Uterine  Cavity. — Intra-uterine  Injections. — 
Continuous  Irrigation  During  Operation. — Antisepsis  and  Asepsis  in 
Operations  through  the  Abdomen :  a,  of  the  Operator  ;  b,  of  the 
Patient ;  c,  of  the  Spray ;  d,  of  the  Instruments. — Sponges. — Com- 
pressed Gauze  Sponges. — Toilette  of  the  Peritoneum. — Cauterization  of 
the  Pedicle.— Preparation  and  Preservation  of  the  Materials  for  Liga- 
ture, Suture,  and  Drainage. — Silk. — Catgut.  —  Silver  Wire. — Horse 
Hair. — Drainage  Tubes, 1-30 

CHAPTER  II. 

Anesthesia  in  Gynecology. 

Local  Anaesthesia. — Cold. — Cocaine. — Suggestion. — General  Anaesthesia. — 
Anaesthesia  for  Exploration. — Ether,  Chloroform. — Mixed  Anaesthesia. 
— Prolonged  Anaesthesia. —  Contra-indications.  —  Condition  of  Heart 
and  Kidneys. — Accidents. — Treatment  of  Accidents,         ....      31-39 

CHAPTER  III. 

Means  for  Wound-Closure  and  the  Control  op  Hemorrhage. 

Sutures.— Needles.— Needle-holders.  —  Intestinal  Sutures.— Suture  Mate- 
rials.—Wire.— Silkworm  Gut.— Silk.— Catgut.— Secondary  Infection  of 
Sutures.  —  Various  Methods  of  Suture.— Interrupted  Suture.— Buried 
Suture  at  Separate  Points.— Continuous  Suture,  Simple  and  on  Sev- 


X  TABLE   OF   CONTENTS. 

PAGE 

eral  Planes. — Mixed  or  Combined  Suture  Suture  after  Laparatomy. — 
— Hseinostasis. — Isolated  Ligature. — Ligature  in  Mass.  —  Chain  Liga- 
ture.— Elastic  Ligature. — Forci pressure. — Drainage  :  1,  of  the  Wound  ; 
2,  of  the  Peritoneum  ;  a,  through  the  Vagina  ;  b,  through  the  Abdom- 
inal Wound. —  Capillary  Drainage.  —  Antiseptic  Tamponade  of  the 
Peritoneum. — Drainage  and  Continuous  Irrigation  of  the  Uterine 
Cavity.  —  Infra-uterine  Tampons.  —  Tamponade  of  the  Vagina  :  a, 
Haemostatic ;  &,  Antiphlogistic, 40-83 

CHAPTER    IV. 

Gynaecological  Examinations. 

Position  of  the  Patient. — Vertical  Position. — Simple  Dorsal  Decubitus. — 
Lithotomy  Position. —  Lateral  or  Sims'  Position. —  Trendelenburg's 
Position. — Genu-pectoral  Position. — Simple  Abdominal  Palpation. — 
Exploratory  Anaesthesia. — Vaginal  Touch. —  Rectal  Touch. — Vesical 
Touch. — Bimanual  Exploration. — Examination  with  the  Speculum. — 
Examination  with  the  Uterine  Sound.  —  Fixation  and  Downward 
Traction  of  the  Uterus. — Artificial  Dilatation  of  the  Cervix. — Pro- 
cedures without  Bleeding  (Laminaria  Tents,  Divulsion,  Dilating 
Bougies).  — Procedures  with  Bleeding  (Division  of  the  External  Orifice, 
Complete  Bilateral  Incision  of  the  Cervix). — Permanent  Dilatation. — 
Intra-uterine  Touch. — Exploratory  Incision  and  Curetting. — Explora- 
tion of  the  Ureters  (Palpation,  Catheterization,  Methods  of  Pawlik 
and  Simon), 84-129 

METRITIS. 
CHAPTER  V. 

Pathology  and  Etiology. 

Definition. — Morbid  Conditions  without  Neoplasm. — Pseudo-metritis. — 
Lesions  of  the  Fundus. — Acute  Metritis. — Acute  Lesions  of  the  Mucous 
Membrane. — Chronic  Metritis. — Lesions  of  the  Parenchyma. — Lesions 
of  the  Mucous  Membrane. — Interstitial  Endometritis.— Glandular  En- 
dometritis. —  Chronic  Polypoid  Endometritis.  —  Endometritis  after 
Abortion. — Lesions  of  the  Cervix. — Ovules  of  Naboth. — Granulations. — 
Folliculitis.  —  Erosions.  —  Ulceration.  —  Ectropion.  —  Mucous  Polypi. 
—  Follicular  Hypertrophy. — Lacerations. — Pathogeny. — Hetero-infec- 
tion.  — Mixed  Infection.  —  Auto-infection. —  Conjugate  Infections. — 
Etiology. — Menstruation. — Copulation. —  Gonorrhoea.  —  Parturition. — 
Laceration  of  the  Cervix. — Traumatism. — Diathesis,        ....  130-168 

CHAPTER  VI. 

Symptoms,  Course,  and  Diagnosis. 

Uterine  Syndroma :  Pain,  Leucorrhcea,  Metrorrhagia,  Dysmenorrhea. — 
Sterility. — Immediate  and  Reflex  Symptoms. —Dyspepsia.— Cough. — 
Neuralgias  and  Neuroses. — Coccygodynia.  —  Hysteria. — Asthenia.— 
General  Condition.— Facies  Uterina. — Physical  Signs  with  Touch, 
Speculum,  and   Uterine  Sound.— Various  Forms  of  Metritis:    Acute, 


TABLE   OF   CONTENTS.  XI 

PAGE 

Catarrhal,  Hemorrhagic,  Chronic,  Painful. — Mucous  Polypi.  —  Fol- 
licular Hypertrophy  of  the  Cervix. — Membranous  Dysmenorrhea. — 
Course  and  Prognosis. — Diagnosis  from  Pregnancy,  Cancer,  Abortion, 
Fibroma,  Salpingitis,  and  other  Diseases  of  the  Adnexa,  Cystitis, 
Proctitis,  Sphincteralgia,  Pulmonary  Tuberculosis,  Dilated  Stomach, 
Diseases  of  the  Heart,  Hysteria, 169-183 

CHAPTER  VII. 

Treatment. 

Prophylaxis. —  The  Curette  in  Retention  of  the  Decidua  after  Abortion. — 
Treatment  applicable  to  All  Forms  of  Metritis:  Girdles,  Tonics,  Hydro- 
therapy.— Treatment  of  Acute  Metritis. — Glycerin  Tampons. —  Pro- 
longed Hot  Injections. — Scarification  of  the  Cervix.  —  Membranous 
Dysmenorrhea. — Acute  Gonorrheal  Metritis. — Treatment  of  Catarrhal 
Metritis. — Vaginal  Injections. —  Intra-uterine  Medication,  Intra-uterine 
Irrigation. — Uterine  Drainage. — Uterine  Tamponade. —  Sweeping  with 
the  Tampon. —  Intra-uterine  Cauterization. — Galvano-cautery. — Caus- 
tic Tampons. — Caustic  Injections. — The  Use  of  the  Curette. — Sterility 
after  Its  Employment.— Technique. —  Accidents.— Perforation  of  the 
Uterus. — Hemorrhage. — Peritonitis. — Treatment  of  Mucous  Polypi  of 
the  Cervix:  Follicular  Hypertrophy,  Ulceration  and  Lacerations  of 
the  Cervix. — Treatment  of  Hemorrhagic  Metritis.  —  Palliative  Treat- 
ment for  Bleeding. — Curative  Treatment. — Castration. — Vaginal  Hys- 
terectomy.— Treatment  of  the  Chronic  Painful  Form  of  Metritis. — 
Scarification. — Ignipuncture. — Dressings. — Local  Applications. — Tam- 
ponade.— Hot  Injections. —  Electricity. —  Massage. —  Amputation  and 
Resection  of  the  Cervix. — Amputation  with  Two  Flaps. — Amputation 
with  One  Flap  (Schroder). — Trachelorrhaphy  or  Emmet's  Operation. — 
Castration. — Hysterectomy, 184-215 


FIBROMA  OF  THE  UTERUS. 

CHAPTER  VIII. 

Pathology. 

Definition. — Histogeny. — Frequency.  — jSTumber.  —  Myomatous  Degenera- 
tion of  the  Uterus.— Size.— Seat :  Fibroma  of  the  Fundus  ;  Interstitial, 
Submucous,  Polypoid  Fibroma.— Fibroma  of  the  Ligaments.— Fibroma 
of  the  Cervix  ;  of  the  External  Os  ;  of  the  Supra-vaginal  Portion,  with 
Pelvic  Development. — Connections  with  the  Uterine  Tissue.  Structure, 
and  Texture.— Telangiectatic  Myomata.— Connections  with  Adjacent 
Organs. — Ascites.— Adhesions.— Torsion  of  the  Pedicle.— Induration.— 
Calcification.— Softening.— Fatty  Degeneration.  —Amyloid  Degenera- 
tion.— CEdema.— Colloid  Degeneration. —  Fibro-cystic  Tumors. —  Lym- 
phangiectatic  Myomata. — Pseudo-cysts. — Inflammation,  Suppuration, 
and  Gangrene.  —  Cancerous  Degeneration. — Adjacent  and  Distant 
Secondary  Lesions  :  of  the  Mucous  Membrane;  of  the  Uterus  and  the 
Tubes  ;  of  the  Liver,  Kidneys,  Heart, 216-231 


Xll  TABLE   OF   CONTENTS. 

CHAPTER    IX. 
Symptoms,  Diagnosis,  and  Etiology. 

PAGE 

Rational  Symptoms  :  Hemorrhage,  Leueorrhoea,  Pain,  Compression  Signs, 
of  Bladder,  Rectum,  Ureters.— Affections  of  the  Heart.— Physical  Signs; 
"Fibrous  Pregnancy,''  Tumor.— Differential  Diagnosis  of  Uterine 
Fibromata,— Fibroma  of  the  Inflammatory  Type  Distinguished  from 
Hemorrhagic  Metritis,  Pregnancy,  Abortion,  Cancer  of  the  Fundus, 
Inflammations  of  the  Adnexa,  Anteflexion,  Retroflexion,  and  Fecal 
Collections. — Fibroma  of  the  Cervix  Distinguished  from  Uterine  Inver- 
sion, and  Polypus  of  the  Fundus.— Submucous  Fibroma  of  the  Fundus 
Distinguished  from  Polypus,  Pregnancy,  and  Cancer  of  the  Fundus. — 
Polypus  of  the  Fundus  Distinguished  from  Submucous  Fibroma,  Cer- 
vical Fibroma,  Uterine  Inversion,  and  Cancer.— Subperitoneal  Ped- 
icled  Fibroma  Distinguished  from  Ovarian  Cysts,  Pregnancy,  Floating 
Kidney,  and  Peritoneal  Cancer.— Sessile  Subperitoneal  Fibroma  Dis- 
tinguished from  Pregnancy.— Fibromata  Included  in  the  Broad  Liga- 
ment (Abdominal  Variety)  Distinguished  from  Tumors  of  the  Ilium, 
Parovarian  Cysts,  Encysted  Tumors  of  the  Tubes,  Ovarian  Cysts.— 
Pelvic  Fibroma  Distinguished  from  Retroflexion,  Haematocele,  Peri- 
and  Parametritis.— The  Uterine  Souffle.— Ascites.— Coincident  Cysts. 
— Symptomatic  Genital  Prolapse.— Symptomatic  Uterine  Inversion. — 
Eventration. — Hernia  of  the  Fibroma. — Course  and  Prognosis.— Influ- 
ence of  the  Menopause  ;  of  Pregnancy. — Fibroma  of  Extreme  Rapidity 
of  Growth.  —  Spontaneous  Expulsion  or  Enucleation.  —  Gangrene.— 
Absorption.— Sterility.— Causes  of  Death,    ........  232-246 

CHAPTER  X. 

Medical   Treatment.      Surgical   Treatment   of    Fibroma   Developing 

Toward  the  Vagina. 

Medical  Treatment,—  Hemostatic  Applications.— Thermal  Treatment.— 
Electricity.— Treatment  of  the  Compression  Symptoms  by  Elevating 
the  Tumor.— Minor  Hemostatic  Operations.— Curetting.— Injections. — 
Bloodless  Dilatation  of  the  Cervix.— Intra-uterine  Scarification.— Surgi- 
cal Treatment  of  Pedicled  and  Interstitial  Fibromata  of  the  Cervix. — 
Surgical  Treatment  of  Polypi  of  the  Fundus  ;  large  Polypi.— Surgical 
Treatment  of  Submucous  Fibroma  of  the  Fundus.— Enucleation. — 
Operative  Technique.— Operation  in  Several  Steps.— After-treatment. 
—Accidents.— Mortality.—  Trans-vaginal  Enucleation.— Vaginal  Myo- 
motomy.— Operative  Technique.  —After-treatment.  —  Mortality.— Va- 
ginal Hysterectomy.— Removal  of  the  Fibroma  through  the  Vagina,     .  247-276 

CHAPTER  XI. 

Treatment  of  Fibromata  with  an  Abdominal  Evolution  ;  Myomectomy 

and  Hysterectomy. 

Historical  Review. — Synonyms.— General  Indications. — Classification  of 
Fibromata  from  the  Operative  Point  of  View.—  Provisional  Hsemo- 
stasis    by    the     Elastic    Ligature.  —  Myomectomy.  —  Intra-peritoneal 


TABLE   OF   CONTENTS.  Xlll 

PAGE 

Enucleation. —  Partial  and  Supra-vaginal  Hysterectomy. — Operative 
Technique. — Treatment  of  the  Pedicle.  —  Intraperitoneal  Method 
(Schroder).  —  Extra-peritoneal  Method  (Hegar).  —  Special  Methods  : 
Olshausen's  Method  (Buried  Elastic  Ligature) ;  Zweifel's  Method 
(Partial  Juxtaposed  Ligatures) ;  Wolfler-Hacker's  Mixed  Method ; 
Sanger's  Method. — Extirpation  of  the  Pedicle :  Total  Hysterectomy 
(Bardenheuer). — Decortication  of  Fibromata  in  the  Broad  Ligaments. 
— Mortality  of  Hysterectomy. — Operative  Accidents.  — Hemorrhage. — 
Wound  of  the  Bladder. — Wound  of  the  Ureter. — Wound  of  the  Intes- 
tine.— Causes  of  Death  after  Abdominal  Hysterectomy. — Hemorrhage. 
— Shock. — Embolism. — Intestinal  Occlusion. — Absolute  and  Compara- 
tive Mortality  of  the  Intraperitoneal  and  the  Extra-peritoneal 
Methods.— Choice  of  Method, 277-315 

CHAPTER  XII. 

Castration  for  Fibroma. 

Historical  Review. — Indications. — Operative  Technique. — Lateral  Incision. 
— Vaginal  Incision.  —  Median  Incision.  —  Ligature  of  the  Pedicle. — 
Atrophy  by  Means  of  Ligatures. — Unilateral  Castration. — Mortality  of 
the  Operation. — Results,  . 316-326 

CHAPTER  XIII. 

Fibroma  Complicating  Pregnancy. 

Effect  of  Pregnancy  on  the  Growth  of  the  Tumor. — Indications  for  the 
Expectant  Treatment. — Compression  Symptoms.  —  Operation  for 
Fibroma  of  the  Cervix. — Operation  for  Polyp. — Induced  Abortion  and 
Premature  Labor. — Caesai-ean  Operation. — Hysterotomy  and  Hysterec- 
tomy.—Porro's  Operation,        .  327-332 

CARCINOMA  OF  THE  UTERUS. 
CHAPTER  XIV. 

Pathology,  Symptoms,  Diagnosis,  and  Etiology  op  Cancer  of  the  Cervix. 

Pathology. — Histogeny. — Anatomical  Forms.  —  Histological  Varieties. — 
Extension  to  Adjacent  Tissues :  Vagina,  Fundus,  Pelvic  Connective 
Tissue,  Urinary  Apparatus. — Secondary  Lesions  of  the  Heart. — Exten- 
sion to  the  Rectum  and  Peritoneum  ;  to  the  Lymph  Ganglia  ;  to  the 
Liver. — Symptoms.  —  Onset.— Latent  Period. — Period  of  Advance. — 
Cachexia. — Termination.  —  Complication  with  Pregnancy. — Differen- 
tial Diagnosis  from  Metritis,  Papilloma,  Mucous  Polyp,  Ulcerated 
Fibrous  Polyp. — Exceptional  Forms;  Hypertrophy  and  Cancer. — 
Papillary  QMeruatous  Sarcoma.  —  Strio-cellular  Myo-sarcoma.  — 
Adeno-Myxo-Sarcoma. — Cartilaginous  Papillary  Fibroma. — Myxoma  : 
Arborescent,  Enchondromatous.  —  Adeno-myxoma.  —  Diagnosis.— Ex- 
tension.— Prognosis. — Etiology, 333-352 


XIV  TABLE   OF   CONTENTS. 

CHAPTER  XV. 

Treatment  of  Cancer  of  the  Cervix. 

PAGE 

Cancer  Limited  to  the  Portio  Vaginalis  and  Not  Extending  to  the  Vaginal 
Culs-de-sac. —  Intra- vaginal  Amputation  of  the  Cervix.  —  Verneuil's 
Method. — Cancer  of  the  Entire  Cervix. —  High  or  Supra-vaginal  Am- 
putation of  the  Cervix. — Schroder's  Method. — Cancer  of  the  Cervix 
Involving  the  Fundus  but  without  Invasion  of  the  Adjacent  Tissues. 
— Vaginal  Hysterectomy. — Operative  Technique. — After-treatment. — 
Various  Modifications  of  the  Operation. — Forcipressure  of  the  Broad 
Ligaments. — Operative  Accidents. — Mortality  of  Vaginal  Hysterectomy 
,  for  Cervical  Carcinoma. — Comparative  Mortality  of  Hysterectomy  and 
Amputation  of  the  Cervix.  —  Causes  of  Death  :  Hemorrhage,  Shock, 
Kidney  Disease,  Septicemia. — Operative  Accidents. — Resume  of  Cases 
of  Operation,  Hysterectomy  and  Amputation  of  the  Cervix. — Hys- 
terectomy through  the  Perineum  and  through  the  Sacrum. — Cancer 
with  Extension  to  the  Adjacent  Tissues.  —  Treatment :  Palliative. — 
Curette  and  Cautery.  —  Treatment:  Symptomatic.  —  Leucorrhcea, 
Hemorrhage,  Erythema  of  the  Vulva,  Gastric  Symptoms,  Pain. — 
Pretended  Specifics. — Cancer  Complicated  by  Pregnancy  ;  Uterine 
Fibroma  ;  Ovarian  Cysts, 353-395 

CHAPTER  XVI. 

Cancer  of  the  Body  of  the  Uterus. 

Definition. — Benign  and  Malignant  Adenoma. — Forms  of  Cancer  of  the 
Fundus. — Epithelioma  of  the  Mucous  Membrane  :  Pathology,  Symp- 
toms, Diagnosis,  Prognosis,  Etiology. — Diffuse  Sarcoma  of  the  Mucous 
Membrane:  Pathology,  Symptoms  and  Diagnosis,  Prognosis,  Etiology. 
— Fibro-sarcoma  :  Pathology,  Symptoms,  Diagnosis,  Etiology. — Treat- 
ment of  Cancer  of  the  Fundus. — Vaginal  Hysterectomy.— Hysterec- 
tomy through  the  Sacrum. —  Supra-vaginal  Hysterectomy. —  Total 
Abdominal  Hysterectomy. — Freund's  Operation. — Mortality. — Pallia- 
tive Treatment,         .        .        .  396-415 

DISPLACEMENTS  OF   THE  UTERUS. 

CHAPTER  XVII. 

General  Considerations.    Classification  of  Displacements.     Anterior 

Deviations. 

Historical  Review.  —  Anterior  Deviations.  —  Anteversion  :  Pathology, 
Etiology,  Symptoms;  Diagnosis  from  Fibroma,  Inflammatory  and 
Hemorrhagic  Exudations,  and  Anteflexion  ;  Treatment. — Anteflexion  : 
Pathology,  Etiology,  Symptoms ;  Diagnosis  of  the  Varieties  ;  Diag- 
nosis from  Fibroma,  Inflammatory  Induration,  and  Vesical  Calculus. 
—Treatment  of  Acquired  Anteflexion.  —  Treatment  of  the  Metritis  ; 
Curetting,  Amputation  of  the  Cervix,  Splitting  of  the  Cervix. — 
Treatment  of  Congenital  Anteflexion;  Reposition,  Dilatation,  Pessaries, 
Castration, 416-433 


TABLE   OF   CONTENTS.  XV 

CHAPTER  XVIII. 

Displacements  of  the  Uterus— Continued.    Posterior  Deviations. 

PAGE 

Retroversion  :  Pathology,  Etiology,  Symptoms,  Diagnosis,  Treatment. — 
Retroflexion :  Pathology,  Etiology,  Symptoms,  Diagnosis,  Treatment. 
— Treatment  of  the  Metritis  :  Cm*etting,  Amputation  of  the  Cervix.- 
Reposition:  Reposition  by  Posture  ;  Bimanual  Reposition  ;  Reposition 
by  the  Uterine  Sound. — Fixation  of  the  Replaced  Uterus. — Pessaries. — 
Operation  of  Alqui<5-Alexander- Adams  ;  Operative  Technique. — Mor- 
tality. —  Results.  —  Indications. — Vaginal  Hysteropexy.  —Methods  of 
Sims,  Amussat,  Richelot,  Sr.,  Byford,  Dole>is,  Skutsch,  Schucking, 
v.  Rabenau,  Sanger,  Nicoletis,  Pean,  Candela,  and  Preund. — Abdomi- 
nal Hysteropexy. — Historical  Review. — Operative  Technique.— Meth- 
ods of  Koeberle"  and  Klotz,  Olshausen  and  Sanger,  Leopold,  Czerny, 
Terrier,  and  the  author. — Prognosis  of  Gastro-hysteropexy. — Indica- 
tions.— Other  Methods. — Kelly's  Method :  Shortening  the  Utero- sacral 
Ligaments  by  the  Abdomen. — Gf.  Wylie's  Method  :  Shortening  the 
Round  Ligaments  by  Intra-peritoneal  Folds.— Caneva's  'Method  : 
Gastro-hysteropexy  without  Laparatomy. — Vaginal  Hysterectomy. — 
Choice  of  an  Operation, 434-479 

CHAPTER  XIX. 

Genital  Prolapse; 

Definition.— Etiology. — Pathology:  1,  Prolapse  of  the  Vagina  alone  ;  2,  of 
Vagina  and  Uterus,  with  Elongation  of  the  Cervix ;  3,  Prolapse  of 
Vagina  and  Uterus  from  Primitive  Hypertrophy  of  the  Cervix  ;  4,  Pro- 
lapse of  Vagina  and  Uterus  without  Hypertrophy  of  the  Cervix. — 
Symptoms. — Course. — Prognosis. — Diagnosis  from  Polyp,  Inversion, 
and  Urethrocele. — Treatment:  Girdles,  Pessaries,  Hysterophores.  Sur- 
gical Treatment. —  Preliminary  Operations:  1,  Formation  of  an  Infe- 
rior Support. — Colpo-perineorrhaphy  ;  Hegar's  Method. — Perineauxe- 
sis  ;  Martin's  Method.— Methods  of  B.schoff  and  Winckel.— Colpo-peri- 
neorrhaphy by  Sliding  Flap;  Doleris'  Method.— Anterior  Elytrorrhaphy. 
— Le  Fort's  Method  of  Vaginal  Occlusion.—  After-treatment  following 
Colpo-perineorrhaphy.— Mortality.— Primary  and  Secondary  Results 
of  Colpo=perineorrhaphy.— 2,  Elevation  ^f  the  Uterus  by  Shortening 
the  Round  Ligaments.— 3,  Suture  of  the  Uterus'  to  the  Abdominal 
"Wall  ;  Gastro-hysteropexy.— 4,  Vaginal  Hysterectomy.— Choice  of  an 
Operation, 480-519 

CHAPTER  XX. 

Inversion  op  the  Uterus. 
Definition.— Classification.  —Pathogeny  and  Etiology. —Pathology.— Re- 
cent Puerperal  Inversion.— Chronic  Inversion.— Symptoms.— Diagnosis 
from  Polyp,  Inversion  Accompanying  Polyp,  and  Simple  Prolapse- 
Course  and  Prognosis.— Treatment,— Methods  Employing  Force.— 
Manual  Reposition.— Instrumental  Taxis.  —  Laparatomy  and  Reduction 
through  the  Abdomen.— Methods  Not  Employing  Force.— Continuous 


XVI  TABLE   OF   CONTENTS. 

PAGE 

Pressure  by  Means  of  the  Air  Pessary,  the  Colpeurynter,  the  Pessary 
with  Elastic  Compression,  Tamponing  with  Iodoform  Gauze.  — Partial 
Hysterectomy  by  Linear  Ecraseur,  Clamp,  Galvano-caustic  Loop, 
Ligature,  and  Elastic  Ligature. — Ligature  with  Elastic  Traction. — 
Partial  Hysterectomy  with  a  Cutting  Instrument.— Total  Hysterec- 
tomy,    520-531 

DEFORMITIES  OF    THE    CERVIX;     ATRESIA;     STENOSIS;     ATROPHY; 

HYPERTROPHY. 

CHAPTER  XXI. 

Atres:'  ,  of  the  Cervix:  Definition,  Etiology,  and  Treatment.— Stenosis  of 
the  Cervix  :  Etiology  and  Pathology. — Symptoms  :  Dysmenorrhea, 
Sterility,  Metritis.— Diagnosis  :  at  External  Orifice;  at  Internal  Orifice. 
— Prognosis. — Treatment :  Slow  Dilatation,  Division  of  External  and 
Internal  Orifices  with  Hemorrhage,  Electrolysis,  and  Stomato- 
plasty Cervical  Amputation.  —  Atrophy.  —  Congenital  Atrophy  of 
Cervix  and  Fundus :  Etiology,  Pathology,  Symptoms,  Diagnosis,  and 
Treatment. — Acquired  Atrophy  :  Pathology,  Etiology. — Senile  At- 
rophy.— Post-puerperal  Involution,  Diverse  Causes,  Symptoms,  and 
Diagnosis.— Prognosis  and  Treatment. —Hypertrophy  of  the  Supra- 
vaginal Portion  of  the  Cervix.  —  Hypertrophy  of  the  Intra- vaginal 
Cervix  :  Etiology,  Pathology,  Symptoms,  Diagnosis,  Prognosis,  Treat- 
ment,    532-546 

DISORDERS  OF  MENSTRUATION. 

CHAPTER  XXII. 

Precocious  and  Delayed  Menstruation. 

Amenorrhea  :  Definition,  Pathogeny,  Etiology. — Amenorrhea  following 
Castration. — Primitive  Amenorrhea. — Secondary  Amenorrhea. — In- 
fluence of  Anaemia. — Influences  from  the  Nervous  System. — Atrophy  of 
the  Genital  Apparatus.  —  Symptoms. — Cutaneous  Eruptions. — Sup- 
plementary Secretions. —  Supplementary  Menstruation  or  Vicarious 
Menses. — Treatment. — Menorrhagia  :  Definition,  Symptoms,  Etiology, 
Pathogeny,  Treatment. — Dysmenorrhea  and  Neuroses  of  Menstrual 
Origin  :  Definition. — Classification :  Ovarian  Dysmenorrhea  and  Uter- 
ine Dysmenorrhea. — Symptoms  and  Diagnosis. — Prolapse  of  the 
Ovary. — Treatment  :  Castration,  Battey's  Operation,  Uterine  Castra- 
tion.— Technique  of  Ovarian  Castration :  by  Abdominal  Incision  ;  by 
Vaginal  Incision, 547-568 


LIST  OF  ILLUSTRATIONS. 


PAGE 

1.  Gynaecological  Operating-room  of  the  Lour  cine-Pascal 5 

2.  Vaginal  Irrigator  for  Suspension 7 

3.  Portable  Vaginal  Irrigator 7 

4.  Fenestrated  Speculum  for  Vaginal  Irrigation 8 

5.  French  Bed-pan  with  Exit-tube 8 

6.  Baker's  Hospital  Bed-pan 9 

7.  Insufflator  for  Iodoform 13 

8.  Recurrent  Catheters  for  Intra-uterine  Irrigation 14 

9.  Budin's  Horse-shoe  Recurrent  Catheter 15 

10.  Continuous  Irrigation  by  Fritschs  Device 16 

11.  Continuous  Irrigation  with  a  Long  Nozzle 17 

12.  Laparatomy  Table  of  Mme.  Horn 19 

13.  Collin's  Rotary  Atomizer 20 

14.  Wiesnegg's  Sterilizing  Oven 26 

15.  Glass  Reel  for  Silk  or  Catgut 27 

16.  Box  of  Reels  for  Silk  or  Catgut 27 

17.  Rolling  Carriage  for  Transferring  Patients  from  Ward  to  Operating-room..  35 

18.  Tongue  Forceps. . .    38 

19.  Large  Mounted  Needles 41 

20.  Orifices  Made  by  Ordinary  and  Hagedorn  Needles 42 

21.  Hagedorn  Needles  ...   42 

22.  Ordinary  Strong  Surgical  Needles. . .   42 

23.  Small  Needle  Holders 43 

24.  Large  Needle  Holders 44 

25.  Intestinal  Sutures 45 

26.  Course  of  Interrupted  Sutures 47 

27.  Continued  Suture 48 

28.  Continued  Suture  in  Layers 49 

29.  Continued  Suture  in  Layers.     Method  of  Fastening  End  of  Thread 50 

30.  Suture  in  Layers  (Etages)  in  Operation  for  Ruptured  Perineum ,  51 

31.  32,  33.  Suture  of  Abdominal  Walls  after  Hysterectomy 52 

34.  -Various  Surgical  Knots 54 

35,  36,  37,  38.  Application  of  the  Continuous  Ligature 55 

39.  Chain  Suture  with  a  Series  of  Needles 58 

40.  Hegar's  Forceps  Temporarily  Holding  an  Elastic  Ligature  in  Place,  while 

a  Permanent  Ligature  is  being  Applied 59 

41.  Elastic  Ligature  Tied 59 

42.  Hegar's  Forceps  for  Temporary  Fixation  of  an  Elastic  Ligature 60 

43.  Elastic  Ligature  Holder 61 

44.  45.  Application  of  Pozzi's  Elastic  Ligature 62 

46.  Segond's  Ligator — Pozzi's  Ligator  Dismounted 65 

47.  Ko3berl6"'s  Haemostatic  Forceps 66 

48.  Billroth's  Forceps  for  the  Compression  of  Fleshy  Pedicles 67 


XV111  LIST   OF   ILLUSTRATIONS. 

*  PAGE 

49,  50,  51.  Clamps  for  Forci pressure  in  Mass 68 

52.  Rubber  Tube  for  Peritoneal  Drainage  with  Forceps  for  Introduction 72 

53.  Glass  Tubes  for  Peritoneal  Drainage 73 

54.  Tait's  Cupper  for  Aspiration  from  Drain 73 

55.  Gauze  Tamponade  of  the  Peritoneal  Cavity  after  Hysterectomy 76 

56.  Apparatus  for  Continuous  Irrigation  of  the  Uterine  Cavity. 77 

57.  Metal  Sheet  for  Continuous  Irrigation 84 

58.  Kelly's  Ovariotomy  and  Perineal  Pads 85 

59.  Basins  for  Di*essings 86 

60.  Patient  in  Modified  Dorsal  Position  on  Chadwick's  Table 86 

61.  Ott's  Leg-holder 87 

62.  Patient  in  Lithotomy  Position  with  Ott's  Leg-holder 88 

63.  64.  Cleveland's  Operating  Table 88 

65.  Kelly-Robb  Leg-holder .  . .  90 

66.  Patient  in  Dorso-sacral  Position  with  Robb  Leg-holder 90 

67.  Patient  in  Sims'  Position  on  Chadwick's  Table 91 

68.  Genu-pectoral  Position    92 

69.  Bimanual  Palpation,  Front  View 98 

70.  Bimanual  Palpation,  Sectional  View 99 

71.  Bimanual  Palpation  in  Retroversion 100 

72.  Fergusson's  Cylindrical  Speculum 101 

72.  Brewer's  Speculum 102 

74.  Simon's  Specula 10S 

75.  Vaginal  Retractor 103 

76.  Sims' Speculum 104 

77.  Tenaculum  and  Depressor 105 

78.  79.  Cleveland's  Self-retaining  Speculum 105 

80.  Uterine  Sound 107 

81.  Fixation  Forceps Ill 

82.  Laminaria  and  Tupelo  Tents  before  and  after  Dilatation 113 

83.  Palmer's  and  Goodell's  Uterine  Dilators 115 

84.  Hegar's  Dilator 116 

85.  Kilchenmeister's  Scissors 117 

86.  The  Portion  of  the  Ureters  Accessible  to  Touch 121 

87.  The  Vesical  Trigone  (Pawlik)  124 

88.  Pawlik's  Ureteral  Catheters , 125 

89.  Ureteral  Catheterism  by  Simon's  Method 127 

90.  Normal  Mucous  Membrane  of  the  Body  of  the  Uterus,  Slightly  Enlarged 

(Wyder) 132 

91.  Normal'Mucous  Membrane  of  the  Cervix,  Slightly  Enlarged  (Wyder) 133 

92.  Section  from  the  Normal  Mucous  Membrane  from  the  Body  of  the  Uterus 

(Cornil) 134 

93.  Normal  Mucous  Membrane  of  the  Uterus  during  Menstruation  (Wyder)  . .  135 

94.  Normal  Placenta  (Friedlander,  Wyder) . . ., 136 

95.  Acute  Septic  Metritis 137 

96.  Acute  Endometritis,  Membranous  Dysmenorrhea  (Wyder) 138 

97.  Chronic  Metritis 139 

98.  Interstitial  Endometritis  with  Partial  Atrophy  of  the  Glands  (Wyder) 141 

99.  Interstitial  Endometritis  with  Complete  Atrophy  of  the  Glands  (Wyder).  142 

100.  Glandular  Endometritis  of  the  Uterine  Body  (Wyder) 143 

101.  Glandular  Endometritis,  Polypoid  Form  (Wyder) 144 

102.  Epithelial  Investment  of  a  Gland  from  the  Body  of  the  Uterus  (Cornil). . .  144 


LIST    OF    ILLUSTRATIONS.  xix 

PAGE 

103.  Glandular  Endometritis  (Cornil) 145 

104.  Endometritis  Post  Abortum .  147 

105.  Simple  Papillary  Erosion 148 

106.  Transverse  Section  through  the  Upper  Part  of  the  Cervix,  Showing  the 

Entire  Mucous  Membrane  (Cornil) 149 

107.  Section  of  the  Mucous  Membrane  of  the  Cervix  in  a  Case  of  Chronic  In- 

flammation (Cornil) 150 

108.  A  Portion  of  the  Mucous  Membrane  of  the  Previous  Figure  more  highly 

Magnified .........  151 

109.  Follicular  Hypertrophy  of  the  Cervix 152 

110.  Mucous  Polypi  from  Follicular  Hypertrophy  153 

111.  Section  of  a  Glandular  Uterine  Polypus  (Cornil) 154 

112.  Genital  Nerves  of  the  Infant 174 

113.  Abdominal  Bandages 185 

114.  Bath  Speculum .186 

115.  Cervical  Scarificators 187 

116.  Sims'  Slide  Applicator 190 

117.  Doleris  Ecouvillon , , .  191 

118.  Braun's  Intra-uterine  Syringe 194 

119.  Curettes 195 

120.  Museux's  Forceps 197 

121.  Uterine  Dressing  Forceps,  Straight  and  Elbowed,  for  Removal  of  Polypi .  200 

122.  Amputation  of  the  Cervix  by  Simon's  Operation 207 

123.  Amputation  of  the  Cervix  by  Schroder's  Operation 208 

124.  Trachelorrhaphy  by  Emmet's  Operation  ;  Showing  Imperfect  Denudation,  210 

125.  Diagram  Showing  Area  of  Denudation  and  Arrangement  of  Sutures  in 

Emmet's  Operation 211 

126.  Emmet's  Operation;  Appearance  of  Cervix  after  Sutures  are  Tied 211 

127.  Small  Interstitial  Fibroid 216 

128.  Submucous  Pediculated  Fibroid 216 

129.  Submucous  QHdematous  Fibroid,  with  Hypertrophy  of  Uterine  Wall 217 

130.  Subperitoneal  and  Interstitial  Fibroids  of  the  Fundus  of  the  Uterus 218 

131.  Interstitial  Fibroid  of  the  Body  of  the  Uterus 219 

132.  Uterine  Polyp  Expelled  into  the  Vagina  but  Preserving  the  Triangular 

Form  of  the  Uterine  Cavity 220 

133.  Subperitoneal  Pediculated  Fibroid 220 

134.  Interstitial  Fibroid  of  the  Posterior  Lip  of  the  Cervix 221 

135.  Small  Muriform  Polyp  of  the  Cervix 222 

136.  Intra-ligamentous  Fibroma 223 

137.  Section  Showing  Macroscopic  Arrangement  of  Fibres  in  a  Uterine  Fibroma,  224 

138.  Section  Showing  Microscopic  Appearance  of  Fibroma 225 

139.  Pediculated  Fibroid,  with  Abdominal  Evolution 227 

140.  Apostoli's  Uterine  Electrode  251 

141.  1.  Tripier's  Unipolar  Electrode.     2.  Apostoli's  Bipolar  Electrode 252 

142.  Museux's  Forceps 258 

143.  Collin's  Tumor  Forceps 259 

144.  Forceps  for  Removal  of  Large  Tumors 260 

145.  Pozzi's  Enucleator 262 

146.  Segond's  Trephine  for  Morcellation  of  Fibroids 263 

147.  Removal  of  a  Fibroma  by  Morcellation  (Pean) 269 

148.  Dentated  Cyst  Forceps  which  may  be  Employed  for  Morcellation 270 

149.  Pean's  Forceps  for  Morcellation 270 


XX  LIST   OF    ILLUSTRATIONS. 


150.  Suture  of  the  Thin  Fold  of  Peritoneum  and  Fibrous  Tissue  Left  after  the 

Detachment  of  a  Firm  Adhesion 281 

151.  Enucleation  of  an  Interstitial  Myoma 282 

152.  Chain  Ligature 285 

153.  Schroder's  Intra-peritoneal  Suture  of  the  Pedicle 286 

154.  Vaginal  Drainage  after  Abdominal  Hysterectomy  (Martin)  287 

155.  156,  157,  158.  Ligature  of  the  Pedicle  by  Zweifel's  Method 293-295 

159,  160.  Welfler-Hacker's  Mixed  Treatment  of  the  Pedicle 296,  297 

161,  162.  Sanger's  Mixed  Treatment  of  the  Pedicle 298,  299 

163.  Horizontal  Section  to  Show  Connections  of  an  Intra-ligamentous  Fibroma,  302 

164.  Decortication  of  an  Intra-ligamentous  Fibroma,  Showing  Suture  of  the 

Cavity  and  Drainage  by  the  Vagina 302 

165.  Hegar's  Forceps  for  the  Cauterization  of  the  Pedicle  after  Castration. 321 

166.  Removal  of  Ovary . . 322 

167.  Papillary  Cancer  of  the  Cervix 334 

168.  Nodular  Cancer  of  the  Cervix ,..,,.., 335 

169.  Ulcerative  Cancer  of  the  Cervix. 335 

170.  Cylindrical  Epithelioma  from  the  Upper  Part  of  the  Cervix 336 

171.  Cylindrical  Epithelioma  of  the  Body  of  the  Uterus 337 

172.  The  Same,  more  highly  Magnified 337 

173.  Carcinoma  (low  power) 338 

174.  Epithelioma  of  the  Cervix,  with  Extension  to  the  Vagina 339 

175.  Epithelioma  of  the  Cavity  of  the  Cervix , 339 

176.  Encephaloid  Epithelioma  of  the  Cervix  Invading  the  Body  of  the  Uterus.  340 

177.  Cancer  of  the  Cervix  Invading  the  Vagina  and  Perforating  the  Bladder  . .  341 

178.  Myxo-sarcoma  of  the  Cervix  (Pernice) 347 

179.  Fibro-adenoma  of  the  Cervix  (Thomas) 347 

180.  Supra- vaginal  Amputation  of  the  Cervix 356 

181.  Intra- vaginal  Amputation  of  the  Cervix 358 

182.  Various  Forms  of  Prehension  Forceps  for  Grasping  the  Cervix  Uteri  in 

Hysterectomy 361 

183.  Relation  of  the  Ureters  and  Uterine  Arteries  to  the  Cervix 362 

184.  Vessels  of  the  Uterus  ;  Uterine  and  Utero-ovarian  Arteries 363 

185.  Vaginal  Hysterectomy  ;  First  Step  (Martin) 364 

186.  Vaginal  Hysterectomy  ;  Second  Step  (Martin) 364 

187.  Bowed  Forceps  for  Compression  of  the  Broad   Ligaments  in  Vaginal 

Hysterectomy  (Doyen) 368 

188.  189.  Vaginal  Hysterectomy  by  Forcipressure  (Pean) 369,  370 

190.  Transverse  Perineotomy  (Zuckerkandl) 379 

191.  Hysterectomy  by  the  Sacral  Method  ;  Line  of  Incision 380 

192.  Lines  of  Resection  of  the  Sacrum 380 

193.  Lines  of  Resection  of  the  Sacrum;  Opening  Obtained  by  Preliminary 

Operation  381 

194.  Lines  of  Resection  of  the  Sacrum  ;  Closure  and  Drainage  of  the  Wound. .  381 

195.  Cutting  or  Sharp  Curettes 385 

196.  Benign  Adenoma  of  the  Uterine  Mucosa 396 

197.  Malignant  Adenoma  of  the  Uterine  Mucosa 398 

198.  Circumscribed  Epithelioma  of  the  Uterine  Mucous  Membrane 400 

199.  Diffuse  Epithelioma  of  the  Uterine  Mucous  Membrane 400 

200.  Diffuse  Epithelioma  with  Circumscribed  Thickening 401 

201.  Epithelioma  of  the  Uterus.     X  120 402 

202.  Epithelioma  of  the  Body  of  the  Uterus.     High  Power  (Cornil) 403 


LIST   OF   ILLUSTRATIONS.  XXI 


203.  Primary  Epithelioma  of  the  Uterine  Body.     X  300  (Cornil) 404 

204.  Mucous  Membrane  of  the  Cervix  Compressed  and  Atrophied  by  a  Cancer 

Developed  in  the  Deeper  Layers  (Cornil) 405 

205.  Sarcoma  of  the  Uterine  Mucous  Membrane 406 

206.  Diffuse  Sarcoma  of  the  Uterine  Mucous  Membrane  (Wyder) 407 

207.  Position  of  Uterus  with  Bladder  Empty 417 

208.  Position  of  Uterus  with  Bladder  Half  Filled  (Waldeyer) 418 

209.  Anteversion 420 

210.  Abdominal  Girdles  for  Anteversion 422 

211.  Dumontpallier's  or  Meyer's  Soft-rubber  Ring  Pessary -422 

212.  Forceps  for  Introduction  of  Ring  Pessary 422 

213.  Graily  Hewitt's  Cradle  Pessary  for  Anteversion . . . 423 

214.  Thomas'  Anteversion  Pessary 423 

215.  Galabin's  Anteversion  Pessary 423 

216.  Various  Forms  of  the  Cervix,  Natural  Size  (Schultze) 424 

217.  Anteflexion  of  Infantile  Origin - 425 

218.  Very  Acute  Anteflexion  with  Hypertrophy  of  the  Vaginal  Portion  of  the 

Cervix : 426 

219.  Anteflexion  from  Contraction  of  the  Utero-Sacral  Ligaments 426 

220.  Anteflexion  with  Posterior  Adhesions 427 

221.  Anteflexion  Simulated  by  a  Fibroma  in  the  Anterior  Uterine  Wall 428 

222.  Sagittal  Discission  of  the  Cervix  in  Cervical  Anteflexion  (Sims) 430 

223.  Stem  Pessaries 431 

224.  Collin's  Hysterotome 432 

225.  Retroversion  with  Adhesions 434 

226.  Retroflexion  of  the  Uterus   from   Subinvolution  of  the  Anterior  Wall 

(Martin) 436 

227.  Extreme  Retroflexion 437 

228.  Retroflexion  of  the  Uterus  in  a  Nullipara , 437 

229.  Extreme  Retroflexion  with  Compression  of  the  Rectum 438 

230.  Reduction  of  a  Retroflexion  in  the  Genu-Pectoral  Position 440 

231.  232.  Bimanual  Reduction  of  a  Retroflexion  or  Version 441 

233.  Replacement  of  a  Retroflexed  Uterus  by  the  Sound 443 

234.  Ring  Pessary  in  Place 444 

235.  Hodge  Pessary . 444 

236.  Introduction  of  a  Hodge  Pessary 445 

237.  Lever  Pessary  in  Place 446 

238.  Albert  Smith  Pessary  for  Retroversion 447 

239.  Mund6  Pessary  for  Retroversion  or  Flexion 447 

240.  Thomas-Munde"  Pessary  in  Place 448 

241.  Cradle  Pessary  in  Place 449 

242.  Landowski's  Pessary 449 

243.  Schultz's  Pessary 449 

244.  Schultz's  Pessary  in  Place 450 

245.  Schultz's  Sleigh  Pessary  451 

246.  Fritsch's  Pessary : 451 

247.  The  Round  Ligament  at  the  External  Abdominal  Ring 453 

248.  Vaginal  Hysteropexy  by  Schtlcking's  Method 457 

249.  Vaginal  Hysteropexy  by  Nicoletis'  Method 459 

250.  251.  Gastro-Hysteropexy,  Olshausen  and  Sanger 462 

252.  Gastro-Hysteropexy,  Leopold 464 

253.  Gastro-Hysteropexy,  Czerny 465 


XXil  LIST   OF   ILLUSTRATIONS. 


254.  Gastro-Hysteropexy,  Terrier 465 

255.  Gastro-Hysteropexy,  Pozzi 466 

256.  Course  of  the    Round    Ligaments  as  Soon  Through    the    Transparent 

Peritoneum  (Wylie) ' '  . .  469 

257.  Hysteropexy  (Wylie) 469 

258.  263.  Varieties  of  Prolapse  of  the  Uterus  and  Vagina 482 

204.  Subdivisions  of  the  Cervix 486 

265.  Conoidal  Amputation  of  the  Cervix 486 

266.  Prolapse  of  the  Uterus  Following  a  Retroversion 487 

267.  Prolapse  of  the  Uterus  with  Anteflexion 488 

268.  Prolapse  of  the  Uterus  with  Retroflexion 489 

269.  Perineal  Air  Cushion . . . 494 

270.  Belt  with  Perineal  Pad 494 

271.  Cup-Shaped  Pessary 494 

272.  Roser-Scanzoni  Pessary . . , 495 

273.  Borgnet  Pessary 496 

274.  Gehrung  Pessary 496 

275.  Amputation  of  the  Cervix  in  Uterine  Prolapse 497 

276.  Colpo-perineorrhaphy  toy  Hegar's  Method 498 

277.  -279.  Colpo-perineorrhaphy  by  Martin's  Method 500 

280.  Colpo-perineorrhaphy  by  Bischoff's  Method 503 

281,  285.  Colpo-perineorrhaphy  by  Flap-splitting,  Dol^ris'  Method 504 

286,  287.  Anterior  Elytrorrhaphy 506 

288.  Stoltz  "  Tobacco  Pouch  "  Operations  for  Cystocele  (Mund<5) 508 

289,  290.  Le  Fort's  Operation  for  Closure  of  Vagina 509 

291.  Scheme  of  Inversion  of  Uterus 520 

292.  Inversion  of  Uterus  Without  Prolapse 521 

293.  Inversion  and  Prolapse  of  the  Uterus  Caused  by  a  Fibroid  Tumor 522 

294.  Inversion  of  the  Uterus 523 

295.  Forceps  with  Semi-annular  Jaws  Guarded  by  Rubber  for  Grasping  the 

Inverted  Uterus  (Perier) 528 

296.  Perier's  Ligature  Holder 529 

297.  300.  Cervical  Stenosis — Various  Forms  of  Conical  Cervix 533 

301,  b02.  Discission  of  the  Cervical  Canal 536 

303.  Hypertrophy  of  the  Supra- vaginal  Portion  of  the  Cervix 542 

304.  Hypertrophy  of  the  Intra-vaginal  with  Elongation  of  the  Supra-vaginal 

Portion  of  the  Cervix 543 

305.  Hypertrophy  of  the  Intra-vaginal  Cervix  with  a  Deep  Biateral  Laceration,  543 


LIST  OF  PLATES. 


Plates  I.  and  II. 

Gynecological  Operating  Room  of  the  Johns  Hopkins  Hospital. . . .  .page      4 

Plates  III.  and  IV. 

Lacerations  of  the  Cervix  (Munde") page  156 

Plate  V. 

Submucous  Fibroid  Spontaneously  Expelled  from  Uterus  and  Vagina, 

page  244 

Plate  VI. 

Hegar's  Extra-peritoneal  Treatment  of  the  Pedicle  after  Supra-vaginal 
Hysterectomy page  290 


CLINICAL  AND  OPERATIYE  GYNECOLOGY. 


CHAPTER   I. 

ANTISEPSIS   IN   GYNAECOLOGY. 

The  general  laws  of  surgical  antisepsis  are  applicable  in  the  main 
to  gynecology,  but  there  are  certain  surgical  details  and  technical 
processes  which  it  is  necessary  to  emphasize  and  describe  at  length. 
These  details  fall  naturally  into  two  divisions;  the  first  relating  to 
operations  through  the  natural  passages  upon  the  vagina,  cervix  uteri, 
and  uterine  cavity;  the  second  to  operations  through  artificial  open- 
ings involving  the  peritoneum. 

Antisepsis  of  Operations  theough  Natural  Openings. 

A.  Of  the  Operator. — Absolute  cleanliness  of  the  hands  is  of  great 
importance  in  general  surgery,  but  is  pre-eminently  a  matter  of  neces- 
sity where  there  is  to  be  manipulation  of  the  vaginal  or  uterine  cavi- 
ties ;  for  in  these  situations  pathogenic  germs  find  a  culture-medium 
essentially  favorable  to  their  development,  and  infection  is  rapidly 
initiated.  The  nails  must  be  carefully  cleaned  with  a  smooth-pointed 
file ;  the  hands  and  arms  to  the  elbow  should  be  scrubbed  for  three 
or  four  minutes  with  soap  and  a  stiff  brush  in  hot  water.  The  towels 
used  should  have  been  rendered  aseptic  in  a  sterilizing  oven.  (Foster's 
experiments  have  shown  the  difficulties  in  the  way  of  complete  disin- 
fection of  the  hands.  Having  carefully  washed  them  in  soap  and 
water,  then  in  an  antiseptic  solution,  and  having  wiped  them  upon  a 
towel  previously  heated  to  140°,  he  plunged  them  into  a  sterilized 
peptone  solution;  which  then  became  the  seat  of  colonies  of  bacteria.) 

From  researches  carried  on  by  Yon  Eiselsberg x  in  Professor  Bill- 
roth's  clinic,  upon  the  various  substances  used  in  the  hospitals  for 
cleansing  the  hands,  it  would  seem  that  the  almond  powder  so  freely 
used  in  obstetric  wards,  is  tainted  with  germs,  cocci,  and  bacilli  in 
great  variety.     Its  use  should  be  absolutely  forbidden.     All  soaps  are. 


2  CLINICAL   AND   OPEKATIVE   GYNAECOLOGY. 

good,  except  the  ordinary  hard  (resin)  soap ;  in  this  Eiselsberg  has 
found  many  pathogenic  spores,  whose  presence  is  quite  accounted  for 
by  the  processes  of  manufacture — the  use  of  impure  fats  and  the  low 
temperature  of  saponification.  The  scrubbing  with  soap  and  water 
should  be  followed  by  washing  in  a  bichloride  solution  of  1 : 1,000. 
All  assistants  and  nurses  should  likewise  cleanse  hands  and  arms  to 
the  elbow  in  the  same  thorough  manner.  Many  operators  consider 
this  method  of  cleansing  insufficient,  and  prefer  to  immerse  hands 
and  arms  in  a  solution  of.  potassium  permanganate  4:1,000,  which 
stains  the  skin  a  violet-brown,  then  removing  the  color  by  a  concen- 
trated solution  of  oxalic  acid,  and  finally  washing  in  water  sterilized 
hj  means  of  the  Chamberland  filter.  I  believe  that  this  method  may 
Ibe  reserved  for  the  exceptional  cases  where  there  has  been  contact 
•with  material  which  is  septic  or  suspected  of  being  so.  Fiirbringer 2 
-advocates  the  use  of  alcohol  at  90°  as  a  wash  for  the  hands,  in  addi- 
tion to  the  soap  and  bichloride.  This  process  has  been  accused  of 
making  the  fingers  stiff  and  diminishing  their  tactile  sensibility.3  I 
do  not  use  it. 

Where  one  is  obliged  to  handle  fetid  substances,  as  in  uterine 
cancer,  etc.,  the  use  of  deodorizers  may  well  supplement  but  not 
xeplace  antiseptics.  Without  them,  the  hands  become  impregnated 
with  a  disagreeable  odor  which  clings  in  spite  of  thorough  washings. 
Poulis,  of  Edinburgh,  finds  that  anointing  them  before  the  operation 
with  spirits  of  turpentine  is  a  sufficient  protection. 

A  vessel  containing  a  1: 1,000  bichloride  solution  should  be  placed 
at  the  side  of  the  operator,  so  that  he  may  from  time  to  time  dip  his 
liands  in  it. 

The  operator  and  his  assistants  should  wear  over  their  ordinary 
garments,  a  blouse,  or  linen  frock,  which  must  be  changed  and  washed 
daily.  For  operations  where  constant  irrigation  is  used,  the  surgeon 
should  further  be  protected  by  a  large  apron  of  waterproof  material 
(see  Fig.  1 ). 

B.  Instruments. — As  far  as  practicable,  the  instruments  used 
should  be  of  the  simplest  possible  construction,  easily  taken  apart  if 
composed  of  several  pieces,  without  cavities  or  grooves  from  which 
impurities  are  removed  with  difficulty.  For  this  reason  we  should 
exclude  slides  on  uterine  sounds,  canulated  suture-needles,  needle 
holders  with  springs,  and,  in  spite  of  their  convenience,  the  ingenious 
invention  of  Jacques  Reverdin,  needles  with  movable  eyes.  Instru- 
ments in  one  piece  are  the  best 


ANTISEPSIS   IN   GYNECOLOGY.  3 

The  instruments,  which  immediately  after  a  previous  operation 
should  have  been  immersed  for  five  minutes  in  boiling  water  and  care- 
fully wiped,  must  again  be  boiled  just  before  the  next  operation,  and 
then  placed  in  a  strong  (5$)  carbolic  solution.  Five  minutes'  immer- 
sion in  boiling  water  is  sufficient  to  destroy  all  germs,  as  has  been 
proved  by  II.  Davidson 4  in  his  culture  •  experiments.  The  bichloride 
solution  cannot  be  used  on  account  of  its  destructive  action  upon 
metals.  Should  the  instruments  have  been  previously  used  upon 
septic  material  (fetid  pus,  sanious  or  gangrenous  matter,  etc.),  these 
precautions  will  be  insufficient.  They  must  then  be  immersed  for  a 
half  hour  in  a  strong  (5#)  carbolic  solution  held  at  the  boiling  point, 
or  kept  for  an  hour  in  a  sterilizing  oven  at  284°  F.,  or  soaked  for 
twelve  hours  in  a  strong  cold  carbolic  solution.  These  processes  have 
a  deleterious  effect  upon  the  instruments,  especially  the  bistouries, 
but  they  are  nevertheless  indispensable. 

C.  Surroundings.  Operating  Boom.  Furniture. — It  is  impor- 
tant that  the  room  used  be  perfectly  clean,  and  free  from  curtains, 
hangings,  mats,  carpets,  etc.,  which  might  retain  dust.  In  a  private 
house,  whatever  room  is  used  for  any  important  gynaecological  op- 
eration should  be  emptied  of  its  furniture  and  thoroughly  cleaned; 
in  a  hospital,  it  is  essential  that  the  floor,  walls,  and  ceiling  of  the 
operating  room  should  be  so  constructed  that  they  may  be  washed 
daily  with  the  hose.  Moreover,  it  is  well  to  have  sterilized  water  and 
antiseptic  solutions  in  jars  with  long  tubes  that  may  be  easily  reached. 
In  Fig.  1,  I  show  the  arrangement  which  I  have  adopted  for  •this  pur- 
pose in  the  hospital  of  Lourcine-Pascal.  It  is  advantageous  to  have, 
in  addition  to  a  high  and  wide  window  at  the  side,  free  ingress  of 
light  from  above.  The  furniture  should  be  as  scanty  as  practicable, 
and  exclusively  of  glass  or  metal,  easily  movable  and  easily  cleaned. 
Fig.  1  shows  several  examples  of  this  style  of  furniture. 

D.  The  Patient.  Antisepsis  of  the  External  Genitals.— The 
patient  should  have  had  a  complete  bath  (preferably  of  bichloride) 
the  evening  before  or  the  morning  of  the  operation.  The  rectum, 
however  small  a  share  it  has  in  the  operation,  should  have  been 
carefully  emptied  by  an  enema  and  afterward  washed  with  a  satu- 
rated solution  of  boric  acid  (50:1,000).  The  catheter  should  be  used 
by  the  surgeon  or  an  assistant  previous  to  the  disinfection  of  his 
hands.  In  all  operations  upon  the  vulva,  the  pubic  hairs  must  be 
shaved,  to  add  to  the  ease  of  the  operation,  as  well  as  to  remove  a 
possible  lodging  place  for  septic  material. 


4  CLINICAL   AND    OPERATIVE    GYNAECOLOGY. 

The  external  genitals  should  be  cleansed  first  with  soap,  water,  and 
a  brush,  then  washed, with  a  1: 1,000  bichloride  solution.  The  vagina 
may  be  washed  with  the  same  solution  diluted  one-half  with  warm 
water. 

In  my  opinion,  there  is  no  objection  to  the  1 : 1,000  bichloride  solu- 
tion as  a  vaginal  injection,  providing  that  it  is  administered  under  the 
conditions,  and  according  to  the  directions,  to  be  given  below.  The 
biniodide  of  mercury  has  been  recommended,  but  it  does  not  seem  to 
offer  any  great  advantages.5  Pinard  and  Bernardy  use  a  solution  of 
biniodide  1 : 4,000  instead  of  a  sublimate  solution  1 : 1,000.  The  use 
of  bichloride  in  gynecology  and  especially  in  obstetrics  has  been 
much  decried  of  late.  Certainly  at  first  it  was  used  in  too  strong 
solutions  and  with  too  little  care,  but  the  reaction  has  reached  the 
other  extreme.  The  papers  published  upon  this  subject  have  not 
always  taken  into  account  the  radical  difference  between  injections 
given  immediately  after  labor,  and  those  administered  under  other 
conditions.  In  the  woman  recently  delivered,  the  vaginal  and  uterine 
cavities  communicate  through  a  more  or  less  gaping  and  softened 
cervix.  Fluid  injected  into  the  vagina,  especially  if  one  be  not  care- 
ful to  separate  its  walls  with  the  fingers,  flows  readily  into  the  uterusr 
accumulates  and  remains  there,  and  is  perhaps  absorbed  by  the  re- 
laxed mucosa,  or  its  desquamated  surface.  Hence  the  accidents  noted 
after  simple  vaginal  injections,6  which  have  been  observed  not  only 
after  the  use  of  bichloride,  but  after  carbolic  solutions.  I  would  here 
point  out  a  danger  attending  the  use  of  aqueous  solutions  prepared 
upon  the  spot  by  diluting  concentrated  solutions  of  carbolic  acid; 
more  especially  if  the  preparation  be  impure,  small  oily  drops  may 
form  which  dissolve  with  difficulty,  and,  as  a  consequence,  the  injec- 
tion, instead  of  being  a  perfect  solution,  is  in  reality  a  toxic  mixture. 
This  is  the  explanation  of  cases  observed  by  Briggs,7  serious  accidents 
resulting  from  the  administration  of  an  injection  of  a  teaspoonful  of 
the  alcoholic  solution  of  carbolic  acid  in  a  pint  of  water,  to  women 
recently  delivered.  It  is  equally  certain  that  the  intra-uterine  injec- 
tion of  a  too  powerful  bichloride  solution  (1: 1,000)  may  be  dangerous 
even  in  non-puerperal  patients,  as  in  the  case  quoted  by  Mijalieff, 
where  such  an  injection,  given  daily  for  twenty-six  days,  for  simple 
metritis,  resulted  in  a  mercurial  nephritis  with  hematuria.  I  pur- 
posely omit  allusion  to  the  experiments  upon  the  vagine  of  female 
rabbits  and  Guinea-pigs,  which  do  not  seem  to  me  to  have  a  bearing 
upon  this  special  point.     Moreover,  one  should  keep  in  mind  the  fact 


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6  CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 

that  the  bichloride  solutions  commonly  employed  are  very  rapidly 
neutralized  by  contact  with  abundant  secretions,  leucorrhcea,  cancer- 
ous ichor,  etc.,  and  lose  both  their  toxic  and  disinfecting  power. 
Ernest  Laplace 8  has  recently  shown  the  instability  of  this  antiseptic, 
and  has  investigated  the  cause  and  its  remedies.     The  mercurial  salt 
is  precipitated  by  albuminoid  matter,  forming  albuminates,  whence 
the  rapid  loss  of  antiseptic  power.     The  following  are  a  few  of  his 
experiments :  To  an  open  tube  containing  a  little  less  than  an  ounce 
(25  cc.)  of  natural  serum,  is  added  about  a  drachm  (5  cc.)  of  sublimate 
solution  1:1,000;  the  development  of  germs  is  not  prevented;  with  7 
minims  of  serum  bacteria  are  present.     In  a  tube  containing  a  drachm 
of  sublimate  solution  1 : 1,000,  with  about  12  minims  of  putrefied  human 
blood  containing  bacteria,  the  microbes  multiply ;  if  a  few  drops  of 
this  mixture  are  cultivated  on  gelatin  according  to  Esmarch's  method, 
at  the  end  of  five  days  we  shall  find  large  colonies  of  the  staphylo- 
coccus aureus.     Laplace  has  found  that  the  addition  of  5:1,000  of 
tartaric  acid  to  the  solution  is  sufficient  to  prevent  the  formation  of 
the  albuminates  of  mercury,  without  impairing  its  power  to  destroy 
every  germ  present.     This  discovery,  most  valuable  for  general  sur- 
gery, may  also  be  utilized  in  gynaecology.     From  my  own  experi- 
ments, I  have  nothing  but  praise  to  award  it. 

I  must  say  a  few  words  about  a  new  antiseptic,  creolin,  which  has 
recently  appeared,  and  has  been  experimented  with  in  gynaecology 
and  obstetrics  by  Baumm  and  Born 9  in  the  Maternity  and  Obstetrical 
Clinic  of  Breslau.  As  a  result  of  their  researches,  it  would  seem  that 
creolin  possesses  certain  decided  advantages,  but  also  certain  draw- 
backs which  tend  to  greatly  limit  its  usefulness.  It  is  extremely  diffi- 
cult to  obtain  a  fixed  product,  its  exact  chemical  composition  not 
having  as  yet  been  determined.  It  is  used  in  solution  of  i:  100  in 
treating  ruptured  perineum,  fissured  nipples,  etc.  If  more  concen- 
trated, it  may  produce  erythema,  or  eschars,  so  that  as  an  antiseptic 
it  would  seem  to  be  inferior  to  a  1 : 8,000  bichloride  solution  (Baumm). 
For  intra-uterine  injections  Born  has  used  a  1 :  100  solution,  for  vaginal 
irrigations  2:100,  with  no  resulting  accident  due  to  absorption.  Be- 
sides its  undoubted  antiseptic  power,  creolin  possesses  the  great  ad- 
vantage of  leaving  the  vagina  soft  and  flexible,  and  even  of  imparting 
to  it  a  degree  of  oiliness  which  is  of  decided  advantage  in  obstetrical 
operations,  and  in  certain  gynaecological  manipulations  when  several 
fingers  have  to  be  introduced  into  the  vagina,  or  where  a  large  tumor 
is  to  be  extracted  through  it  (enucleation  of  fibroid  bodies,  vaginal 


ANTISEPSIS   IN   GYN/ECOLOGT.  7 

hysterectomy).  We  know  that  solutions  of  the  bichloride  of  mercury 
and  even  those  of  carbolic  acid  have  the  opposite  effect  of  stiffening 
and  roughening  the  vaginal  mucosa,  leading  often  to  serious  incon- 
venience. This  is,  I  believe,  the  only  useful  application  of  creolin. 
The  opacity  of  the  solution  renders  it  unfit  for  the  immersion  of  in- 
struments. 

Naphthol  /?,  used  by  Bouchard  for  intestinal  antisepsis,  has  been 
recently  extolled  for  surgical  dressings,  either  in  solution  or  as  a 
saturated  gauze.10     It  has  the  advantage  of  being  very  slightly  poi- 


Fig.  2. — Vaginal  Irrigator  for  Suspension. 


Fig.  3.— Portable  Vaginal  Irrigator. 


sonous,  and  seems  destined  to  render  real  service.     The  aqueous  solu- 
tion contains  only  two  parts  in  a  thousand. 

Vaginal  injections,  to  be  truly  cleansing,  should  be  given  accord- 
ing to  certain  definite  rules.  A  jjortable  cylindrical  can,  to  which  is 
attached  a  long  tube  ending  in  the  nozzle  (Figs.  2  and  3),  should  be 
fixed  at  a  slight  height  above  the  operator,  or  held  up  by  an  assistant. 
The  person  who  gives  the  injection  places  the  canula  in  the  vagina, 
introducing  by  its  side  the  index  and  middle  fingers,  which  are  gently 
pushed  up  to  the  cul-de-sac,  then  firmly  pressed  in  every  direction  to 
open  out  the  folds  of  the  vagina  and  permit  of  their  thorough  cleans- 
ing.    If  this  procedure  be  neglected,  some  cause  of  infection  will 


s 


CLINICAL   AND    OPERATIVE   GYNECOLOGY. 

1 


surely  remain.     The  surgeon  or  his  assistant  should  himself  give  such 
an  injection  before  an  operation ;  it  is  what  I  call  rinsing  the  vagina. 

All  canulse  to  be  used  by  the  surgeon  should  be  of  strong  glass 
with  one  terminal  orifice,  for  the  water  should  be  directed  toward  the 
cul-de-sac  and  the  cervix,  cleaning  the  vagina  upon  its  return  only. 


Fig.  4.— Fenestrated  Speculum  for  Vaginal  Irrigation. 

For  injections  to  be  administered  by  the  patient  herself,  it  is  best,  to 
avoid  all  possibility  of  introducing  the  tube  into  the  os  uteri,  to  have 
a  canula  with  several  openings  on  the  side  of  a  terminal  enlargement. 
It  is  also  a  convenience  to  use  a  wire  speculum,  which  accurately  fits 
the  canula,  and  which  opens  out  the  vagina  and  permits  of  thorough 
irrigation  (Fig.  4).  The  patient  should  lie  upon  a  pan  or  a  rubber 
sheet  arranged  to  carry  the  fluids  into  a  pail  (Figs.  5  and  6). 


Fig.  5.— French  Bedpan  with  Exit-tube. 


The  accidents  liable  to  occur  from  vaginal  injections  and  the  dan- 
ger of  wounding  the  cervix  or  allowing  liquid  to  enter  through  it, 
have  been  greatly  exaggerated.  Some  physicians  have  even  gone  so 
far  as  to  forbid  the  use  of  the  canula.  This  is,  I  think,  a  grave  error. 
You  should  simply  instruct  the  patient  to  insert  the  instrument  to  a 
depth  of  six  to  eight  centimetres  (three  inches)  only,  or  about  a  fin- 
ger's length. 


ANTISEPSIS   IN"   GYNECOLOGY. 


9 


Rubber  carmine,  which  are  not  easily  cleaned  and  disinfected, 
should  be  discarded. 

Curved  canulre  possess  no  advantage  over  straight  ones. 

During  the  week  preceding  the  operation,  the  x>atient  should  take 
an  antiseptic  injection  (sublimate  solution,  1:2,000)  morning  and 
evening;  after  which  a  small  pad  of  iodoform  gauze  is  to  be  inserted  in 
the  vagina.  On  the  day  of  the  operation  three  injections  are  to  be 
given,  the  first  two  at  intervals  of  an  hour,  the  third  at  the  very 
moment  of  the  operation ;  I  will  point  out  later  the  reason  for  this 
method  of  procedure. 

After  a  vaginal  injection,  especially  of  corrosive  sublimate,  one 
should  be  careful  to  press  down  upon  the  fourchette  in  such  a  manner 
as  to  insure  the  escape  of  all  the  fluid.     In  many  women,  the  terminal 


Fig.  6. — Hospital  Bed-pan  (or  Baker's  Bed-pan). 


portions  of  the  vagina  and  tbe  vulva  are  of  so  firm  a  quality  that 
much  fluid  may  remain  imprisoned  in  the  upper  part  of  the  canal,  and 
give  rise  to  the  various  accidents  due  to  absorption.  I  have  myself 
witnessed  several  minor  casualties  due  to  this  cause. 

There  is  a  wide-spread  opinion  that  an  antiseptic  injection  should 
follow  and  not  precede  minor  gynaecological  procedures — as  examina- 
tion, catheterization,  dilatation,  etc.  This  is  a  grave  error.  Antisep- 
sis is  most  needed  before  any  such  manipulation.  The  observations 
of  Kaltenbach n  upon  the  auto-infection  of  parturient  women  might 
have  caused  a  suspicion  of  the  existence  of  a  condition  of  latent  in- 
fection, so  to  speak,  of  the  female  genital  organs,  especially  during 
the  puerperal  period.  The  researches  of  Winter12  have  recently 
placed  this  fact  beyond  dispute.  The  genital  tract,  vagina,  and 
cervix  uteri  of  a  healthy  woman,  contain  pathogenic  germs  ;  the 
Staphylococcus  pyogenes  aureus,  citreus,  albus,  and  streptococci  of 


10  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

three  varieties  have  been  recognized  by  their  several  distinct  charac- 
teristics and  methods  of  culture.  But,  and  most  important,  thfir 
virulence  seems  to  be  attenuated  and  latent,  since  the  inoculation  of 
animals  with  these  germs  and  their  cultures  has  been  without  result.. 
Notwithstanding  this,  they  are  a  perpetual  menace,  for  these  inert 
organisms  may,  at  the  slightest  septic  impulse  from  without,  germinate 
and  fructify  with  the  most  terrible  consequences.  Moreover,  there  is 
no  proof  that  these  germs,  innocuous  so  long  as  they  remain  in  their 
ordinary  habitat  below  the  orifice  of  the  internal  os  uteri,  may  not 
reacquire  virulent  properties  if  they  are  suddenly  carried  beyond  this 
boundary.  That  germs  may  be  carried  into  the  uterus  by  the  use  of 
the  sound  and  by  manual  touch  has  been  proved  beyond  a  doubt 
by  Winter's  examinations  of  specimens  removed  by  hysterectomy 
shortly  after  these  operations.  The  consequences  of  these  remarkable 
experiments  are  important.  As  regards  the  disinfection  of  the  vagina 
prior  to  operation,  they  make  its  necessity  apparent.  Is  it  possible, 
by  means  of  the  most  carefully  administered  injection,  to  get  entirely 
rid  of  the  micro-organisms  quartered  in  the  cervix  ?  Steffeck 13  has 
made  a  particular  study  of  this  subject,  from  which  he  draws  the 
following  instructive  conclusions: 

1.  After  a  vaginal  injection  of  one  litre  of  a  1 : 3,000  sublimate 
solution,  as  many  germs  as  before  are  found  in  the  cervix;  only  the 
vagina  has  been  cleansed : 

2.  After  the  same  injection,  in  which  the  vaginal  washing  has  been, 
done  with  the  aid  of  one  finger  as  described  above,  if  some  of  the 
vaginal  mucus  be  inoculated  upon  agar-agar,  a  number  of  colonies 
will  develop,  less  numerous,  however,  than  in  the  first  case. 

3.  After  the  same  performance  aided  by  two  fingers,  two  of  every 
three  cultures  will  remain  sterile. 

4.  As  a  final  experiment,  the  injection  of  the  vagina  and  the 
cleansing  of  the  cervix  are  accomplished  in  the  following  manner: 
One  finger  is  pushed  as  deeply  as  possible  into  the  cervix ;  another 
ringer  opens  and  permits  a  thorough  washing  of  the  anterior  cul-de-sac 
— then  the  two  fingers  are  changed*  about  in  such  a  way  as  to  cleanse 
the  posterior  cul-de-sac;  finally  the  stream  of  water  is  sent  directly 
into  the  os  externum.  After  so  thorough  a  washing  as  this,  all  cul- 
ture experiments  have  been  without  result,  while  before  this  disinfec- 
tion, the  tube  cultures  showed  from  50  to  100  colonies.  As  might 
be  expected,  tiiis  disinfection  is  of  short  duration,  as  more  germs 
come  from  the  supra-vaginal  portion  of  the  cervix  through  the  os 


ANTISEPSIS   IX   GYNAECOLOGY.  11 

uteri,  and  at  the  end  of  an  hour  may  be  found  in  the  lower  portion  of 
the  cervix.  By  repeating  the  injection  for  a  second,  and  then  a  third 
time  at  intervals  of  an  hour,  the  germs  may  be  destroyed  for  a  longer 
time;  Steffeck  having  found  that  in  such  a  case  the  mucus  was  free 
from  germs  for  live  days. 

This  process  of  successive  sterilizations  is  somewhat  tedious,  but  it 
reduces  to  a  minimum  the  chances  of  auto-infection.  This  is  the  rea- 
son why  I  recommend  the  administration  of  three  consecutive  injec- 
tions at  intervals  of  an  hour,  previous  to  every  operation.  No  sound 
or  dilator  should  ever  be  introduced  into  the  uterus,  without  this 
thrice  repeated  disinfection  of  the  vagina  and  cervix. 

To  the  omission  of  this  precaution  may  be  traced  the  numerous 
accidents  following  these  operations  even  when  they  are  apparently 
done  under  strict  antisepsis.  If  we  have  to  do  with  a  disease  causing 
a  foul  odor,  as  cancer,  sloughing  fibroid,  etc.,  the  antiseptic  should  be 
preceded  by  a  deodorizing  injection  (which  is  at  the  same  time  in  itself 
slightly  antiseptic)  of  a  quart  of  hot  water  to  which  are  added  two  or 
three  teasrjoonfuls  of  Labarraque's  solution  of  chlorinated  lime  or 
Pennes'  vinegar.  To  wash  the  rectum  and  the  bladder,  use  either  a 
solution  of  boric  acid  (30  : 1,000)  or  of  salicylic  acid  (1:1,000),  both  of 
which  are  non-irritating  to  the  mucous  membranes. 

For  dressings,  iodoform  gauze  should  be  used  almost  exclusively. 
That  which  we  ordinarily  obtain  as  an  article  of  commerce  is  supposed 
to  contain  from  10  to  30^  of  iodoform.  Where  large  amounts  are 
needed,  it  is  more  economical  and  better  to  have  it  prepared  by  some 
one  trustworthy  person.  Ten  yards  of  plain  gauze  sterilized  by  boil- 
ing, are  cut  into  pieces  of  a  yard  each,  soaked  in  a  solution  of  iodo- 
form (50),  glycerin  (100),  and  ether  (700),  passed  through  a  wringer, 
hung  up  in  an  isolated  chamber  which  is  darkened  and  heated  to  85° 
F.,  and  dried,  after  which  it  is  placed  in  tightly-closed  tin  boxes. 

Some  curious  experiments  made  by  von  Eiselsberg 1  in  Billroth's 
clinic,  upon  supposedly  carefully-prepared  gauze,  demonstrated  the 
fact  that  it  often  (eleven  times  out  of  thirty)  contained  germs  whose 
presence  was  readily  shown  by  means  of  culture.  If  the  gauze,  before 
the  addition  of  the  iodoform,  was  subjected  to  a  temperature  of  212°  F. 
(easily  done  by  boiling  it),  the  cultures  remained  sterile  in  the  pro* 
portion  of  18  out  of  20.  This  preliminary  precaution  of  sterilizing 
should  never  be  omitted. 

It  would  be  still  better  to  heat  the  gauze  to  250°  F.  in  a  steam  ster- 
ilizer u  in  order  to  destroy  both  germs  and  spores.     But  this  apparatus 


12  CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 

is  not  everywhere  obtainable,  and  sterilization  by  means  of  boiling 
water,  if  not  theoretically  perfect,  certainly  seems,  to  produce  suffi- 
ciently excellent  practical  results. 

It  may  seem  surprising  that  iodoform  alone  does  not  suffice  to 
destroy  all  germs.  As  regards  this  point,  we  must  refer  to  the  re- 
searches of  Heyn  and  Rosving.15  They  have  proved  that  iodoform 
in  itself  is  not  a  germicide,  is  not  even  an  obstacle  to  the  development 
of  germs.  De  Ruyter  (of  Berlin)  and  Lubbert  (of  Wurzburg 16)  have 
come  to  the  same  conclusions,  which  have  been  further  confirmed  by 
the  recent  experiments  of  C.  B.  Tilanus.17  Shall  we  conclude  that 
iodoform  in  vivo  is  not  an  antiseptic  in  the  presence  of  pathogenic 
ferments  ?  Certainly  not.  The  researches  of  Behring 18  (of  Bonn)  will 
give  the  solution  to  this  seeming  contradiction.  According  to  this 
authority,  as  leucomaines  and  ptomaines  form,  iodoform  acts  upon  and 
destroys  them  by  a  process  of  reduction.  It  may  be  considered  as  an 
established  fact,  that  it  is  not  possible  to  have  any  dressings  which  will 
be  absolutely  aseptic.19  '  You  may  keep  them  from  all  contact  with 
the  air  in  tightly-closed  metal  boxes  (an  indispensable  precaution,  be 
it  noted) ;  but  whenever  the  box  is  opened  the  germs  may  enter.  It 
is  better,  therefore,  to  use  antiseptic  gauze  (iodoform)  rather  than 
aseptic  gauze  which  has  simply  been  sterilized  in  a  moist  chamber. 
Nevertheless,  if  sterilization  were  applicable  on  a  large  scale,  not  only 
to  the  dressings,  but  to  all  the  bedding  as  well,  it  would  no  doubt  be 
all-sufficient.  In  Bergmann's  clinic,  where  everything  is  thus  care- 
fully purified,  the  effort  is,  as  far  as  possible,  to  replace  antisepsis  by 
asepsis,  and  for  this  reason  gauze  which  has  simply  been  sterilized  is 
used  in  many  cases  as  a  dressing.20 

If  symptoms  of  absorption  render  necessary  the  substitution  of 
some  other  substance  for  iodoform,  sterilized  and  sublimated  gauze 
should  be  used.  This  may  be  easily  obtained  by  first  boiling  the 
gauze  for  an  hour  in  a  solution  of  sodium  carbonate  20:1,000,  to  re- 
move all  stiffening,  then  for  an  hour  in  a  1 : 1,000  solution  of  bichloride. 
It  is  then  dried  in  a  sterilizing  oven  and  preserved  in  tightly-closed 
boxes  or  jars. 

I  have  used  salol  and  iodol,  and  have  found  them  very  inferior  to 
iodoform  and  sublimate.  As  to  carbolized  gauze,  it  so  quickly  loses 
its  antiseptic  properties  that  it  is  not  to  be  depended  on;  moreover,  it 
is  slightly  irritating. 

Antisepsis  of  t?ie  Cervix  and  Uterine  Cavity. — After  operations 
upon  the  uterus  or  the  cervix,  it  is  well  to  leave  some  antiseptic  in 


ANTISEPSIS   IX   GYNECOLOGY.  13 

contact  with  the  cervical  canal.     I  have  used  small  crayons  made- 
according  to  this  formula  of  Yon  Hacker: 21 

B   Iodoformi  pulv.,     .         .  20.00  gm.         3  v. 

Grummi  acacise, 
Glycerini, 
Amyli,      .        .        .         .     aa  2.00  gm.        gr.  xxx. 

M.     S.  To  be  made  into  sticks  of  the  same  calibre  as  the  ordinary 
sticks  of  nitrate  of  silver. 

These  crayons  have  the  advantage  of  being  very  manageable,  and 


Fig.  7.— Insufflator  for  Iodoform. 

they  can  be  inserted  to  quite  a  depth  into  the  uterus ;  but  sometimes 
(doubtless  through  some  error  in  their  manufacture)  they  dissolve  in- 
completely, and  their  presence  gives  rise  to  colicky  pains.  I  havo 
therefore  abandoned  their  use,  and  content  myself  with  dusting  iodo- 
form upon  the  cervix,  or  blowing  it  into  the  cavity  by  means  of  a 
special  insufflator  (Fig.  7),  leaving  besides  in  contact  with  the  cervix  a 
tampon  of  iodoform  gauze. 

The  disinfection  of  the  apparatus  used  in  dilating  the  cervix  is  one 
of  the  most  important  points  for  our  consideration.  I  do  not  uso 
tirpelo  or  prepared  sponge  tents,  regarding  them  as  much  inferior  to 
the  laminaria.  This  even  may  be  a  source  of  infection  if  we  neglect 
certain  precautionary  measures.     There  are  two  methods  of  rendering 


14 


CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 


it  antiseptic ;  either  immersion  in  a  concentrated  solution  of  carbolic 
acid  in  rectified  spirits,  which  is  the  one  adopted  by  Martin ;  or  plac- 
ing the  tents  in  ether  saturated  with  iodoform,  to  which  it  is  well  to 
add  a  tenth  part  of  alcohol  (Hern2,  of  Darmstadt;  Doleris,  etc.). 
Whichever  method  be  chosen,  the  tent  before  using  should  be  rapidly 


'      W 


1.  Bozeman-Fritsch's.  2.  Oliver's.  3.  Collins', 

Fig.  8.— Recurrent  Catheters  for  Intra-uterine  Injections. 


washed  in  a  solution  of  carbolic  acid  20:1,000  or  of  corrosive  subli- 
mate 1:1,000. 

Intra-uterine  injections  in  gynaecology  are  far  from  possessing  the 
same  danger  that  they  do  in  obstetrics,  excepting  where  the  uterine 
cavity  is  much  dilated  and  offers,  after  an  operation,  a  large  denuded 
surface  (enucleation  of  fibromata,  curetting  a  cancer  in  the  fundus, 


ATSTTISEPSIS    IN    GYNAECOLOGY, 


15 


etc.).     In  a  case  like  this,  the  conditions  are  very  similar  to  those  of  a 
uterus  after  delivery,  so  far  as  the  absorptive  area  is  concerned. 

When  the  uterine  cavity  is  not  specially  dilated  (as  after  curet- 
ting for  catarrhal  or  hemorrhagic  endometritis),  there  is  no  objection  to 
using  a  bichloride  solution  1:2,000,  if  one  has  a  double-current  cathe- 
ter of  hard-rubber,  glass,  or  celluloid.  But  as  most  instruments  are  of 
metal  which  is  attacked  by  the  mercurial  solution,  it  is  better  to  use 
a  one-per-cent  carbolic  solution.  This  must  be  tepid  and  one  may  use 
a  pint  or  more,  until  from  the  ax>pearance  of  the  fluid  as  it  comes  from 
the  uterus  it  can  be  seen  that  the  cleansing  has  been  thoroughly  ac- 
complished. The  number  of  tubes  for  intra-uterine  injections  has 
greatly  increased  of  late.  I  limit  myself  to  mentioning,  without  de- 
scribing, those  of  Pajot,  Budin,  Pinard,  Militano,  Doleris,  Segond, 
and  Mathieu.    When  the  uterine  cavity  is  not  enlarged,  I  use  the 


15 


i«s 

(H)  (h)  (h  <n>  n 


Fig.  9.— Budin's  Horse-shoe  Recurrent  Catheter  for  Intra-uterine  Irrigation. 

Bozemann-Fritsch  instrument  (Fig.  8),  after  dilating  the  cervix,  if  that 
be  necessary.  If  the  uterus  is  much  enlarged,  no  danger  attends  an 
injection  given  with  an  ordinary  sound  or  canula,  providing  that  the 
pressure  of  water  be  not  too  great,  as  the  liquid  can  easily  return 
around  the  canula. 

Should  the  cavity  of  the  uterus  need  powerful  disinfection  (as  in 
certain  cases  of  gangrenous  fibromata,  intra-uterine  cancer  with 
putrid  fungosities,  etc.),  it  would  be  well  to  use  bichloride  1 : 2,000;  after 
its  prolonged  application,  it  must  be  followed  by  a  second  intra- 
uterine injection,  simply  to  wash  away  any  of  the  poisonous  antisep- 
tic which  might  remain.  For  this  purpose  I  would  recommend  water 
sterilized  in  the  Chamberland  filter  and  then  boiled,  to  which  I  would 
add  6:1,000  of  sea  salt;  this  modifies  its  irritating  and  absorptive 
powers  by  causing  its  composition  to  more  nearly  approach  that  of  the 
serum  of  the  blood.     I  make  frequent  use  of  this  fluid  for  injections 


16 


CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 


that  are  to  be  purely  aseptic,  whenever,  for  any  reason,  the  use  of 
antiseptics  is  contra-indicated. 

Before  leaving  the  subject  of  the  antisepsis  of  the  external  genitals, 
the  vagina,  and  the  cervix,  I  would  say  a  word  in  reference  to  a  pro- 
cedure which  is  at  the  same  time  an  adjuvant  in  an  operation  and  a 
method  of  disinfection.  I  refer  to  continuous  irrigation.  It  may  be 
accomplished  by  means  of  a  special  sj>eculum  (Fig.  10),  or  more  simply 


Tig.  10.— Showing  how  Continuous  Irrigation  during  Operation  may  be  Maintained  by  Fritsch's 
Device,    a,  End  of  irrigating  canula  to  which  rubber  tube  is  to  be  attached. 


"by  the  "help  of  a  long  canula  which  one  of  the  assistants  must  grasp 
m  his  hand,  supporting  his  wrist  upon  the  pubis,  while  in  the  same 
hand  he  holds  another  instrument  (a  retractor  or  a  tenaculum,  Fig. 
11).  I  use  for  this  irrigation  carbolized  water  (10 : 1,000),  at  95°  to  115° 
F.  Its  strength  must  be  diminished  to  5:1,000  if  the  irrigation  lasts 
for  any  length  of  time,  otherwise  painful  excoriations  will  be  the 
result.     The  slender  stream  of  water  which  constantly  flows  upon  the 


ANTISEPSIS    IN   GYNAECOLOGY. 


17 


operating  field,  and  can  be  increased  or  diminished  at  will,  lias  a  two- 
fold advantage:  it  washes  away  the  blood,  thus  dispensing  with  the 
necessity  of  sponges  or  their  substitutes,  and  it  keeps  the  wound 
bathed  in  an  antiseptic  fluid  which  is  a  far  better  protection  against 
the  germs  in  the  atmosphere  than  even  the  spray.  In  all  operations 
upon  the  vulva,  vagina,  and  cervix,  the  use  of  continuous  irrigation  is 
to  me  a  matter  of  routine  practice ;  I  can  scarcely  praise  it  too  highly. 
Sponges  I  never  use,  as  I  consider  pledgets  of  absorbent  cotton, 


Fig.  11.— Continuous  Irrigation  with  a  Long  Nozzle;  also  Shows  Position  of  Assistants. 


either  dry  or  soaked  in  a  bichloride  solution,  which  is  then  squeezed 
out,  to  be  far  superior.     If  used  dry,  it  is  well  to  wrap  each  in  gauze. 

Laparotomy. 

I  will  now  take  up  the  special  antiseptic  precautions  which  are  to 
be  used  in  a  laparatomy. 

A  serious  preliminary  point  arises :  How  does  it  happen  that  oper- 
ators of  great  authority,  as  Lavvson  Tait  and  Bantock,  for  example, 
disapprove  of  antisepsis,  regarding  it  as  useless  and  even  dangerous, 
and,  in  spite  of  this  opinion,  obtain  the  most  superb  results  ? 22  .Does 
not  this  fact  greatly  impair  the  value  of  the  minute  precautions  whick 
we  are  about  to  advise  'i 


IS  CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 

The  contradiction  is  more  apparent  than  real,  and  to  convince 
yourself  of  this  it  is  only  necessary  to  follow  in  detail  the  methods  cf 
procedure  adopted  by  these  operators  whom  I  have  quoted.  You  will 
see  that  if  they  cannot  be  called  antiseptic,  they  are  eminently  and  to 
an  extreme  degree  aserjtic.23  Now  for  a  laparatomy  and  all  intra- 
peritoneal operations,  asepsis  is  not  only  equal  but  far  superior  to 
antisepsis.  In  fact,  considering  the  delica  cy  of  the  endothelium  lining 
serous  cavities,  an  antiseptic  solution  strong  enough  to  exert  any 
.action  would  injure  this  tissue  and  perhaps  be  followed  by  results 
which  would  endanger  the  success  of  the  operation.  "Rigid  asepsis, 
then,  should  be  the  rule  for  the  interior  of  the  abdomen,  antisepsis 
being  reserved  for  the  exterior.24  If,  moreover,  you  will  note  the  fact 
.that  after  a  laparatomy  and  the  accurate  fitting  together  and  suture 
of  the  abdominal  walls,  there  is,  so  to  speak,  no  longer  any  wound, 
you  can  understand  why  the  omission  of  antiseptics  in  the  dressings 
may  be  unattended  by  untoward  results.  Notwithstanding  all  this,  I 
consider  such  omission  to  be  an  error. 

A.  The  operator  and  his  assistants  must  be  absolutely  clean.  For 
forty-eight  hours  previous  to  the  operation,  none  of  them  should 
have  been  in  a  dissecting  room,  nor  present  at  an  autopsy,  nor  have 
handled  an  anatomical  specimen  or  septic  wound. 

On  the  other  hand,  they  should  have  taken  either  a  vapor  or  bi- 
chloride bath,  followed  by  vigorous  friction  and  soaping  of  the  whole 
body. 

A  long  and  perfectly  clean  linen  garment  should  cover  their  ordi- 
nary clothes.  The  hands  and  arms  should  be  disinfected  according  to 
directions  given  above.  After  these  ablutions  they  must  be  careful  to 
touch  nothing  which  has  not  been  disinfected,  nor  to  shake  the  hand 
of  any  friend.  If  necessary,  one  may  wear  gloves  which  have  been 
sterilized  by  heat  until  the  very  moment  of  the  operation. 

The  number  of  assistants  should  be  as  restricted  as  possible  in 
order  to  diminish  the  chances  of  infection.  One  is  usually  sufficient 
for  the  operation  itself;  a  second  to  prepare  and  hand  sutures  and 
ligatures.  The  surgeon  himself  will  take  his  instruments  from  the 
receptacles  where  they  are  lying  in  an  antiseptic  solution. 

No  one  should  operate  upon  the  abdomen  if  there  be  the  smallest 
sore  or  suppurating  scratch  upon  the  hands,  for  no  rubber  finger 
shield  can  fully  protect  the  peritoneum  from  possible  infection. 

B.  The  patient  has  on  the  previous  evening  been  given  a  soap  or 
sublimate  bath.     For  several  days  she  has  had,  night  and  morning,  a 


ANTISEPSIS    IX    GYNAECOLOGY, 


19 


vaginal  injection  of  bichloride  1:2,000,  after  which  a  pad  of  iodoform 
gauze  has  been  placed  in  the  vagina.  The  bowels  have  been  emptied 
by  a  purge  the  day  before,  and  by  an  injection  in  the  morning.  An 
assistant  uses  the  catheter,  and  immediately  disinfects  his  hands. 
The  hairs  are  shaved,  the  abdomen  is  washed  with  soap  and  water 
with  a  brush,  then  with  ether,  and  finally  with  bichloride  1:1,000, 
taking  especial  care  to  clean  the  cutaneous  folds  of  the  umbilicus. 
The  abdomen  is  then  covered  with  compresses  saturated  with  subli- 
mate solution,  and  these  remain  in  place  for  the  time,  however  short, 
which  elarjses  between  the  cleansing  and  the  operation. 


Fig.  12.—  Laparatomy  Table  of  Mme,  Horn.  Employed  by  Martlv. 

C.  In  a  hospital,  a  special  room  is  reserved  for  laparatomies.  It 
is  as  far  as  possible  from  the  wards  in  which  are  patients  with  sup- 
purating or  septic  wounds,  from  the  water  closets,  and,  in  short,  from 
all  sources  of  infection.  The  corners  should  be  rounded  off;  there 
must  be  no  recesses  or  places  not  easily  accessible  for  cleansing  pur- 
poses. All  the  furniture  should  be  movable;  seats,  tables,  stands, 
should  all  be  of  metal,  enamelled  or  varnished,  or  of  glass.  After  each 
operation,  the  wall  should  be  washed  with  a  hose  attached  to  a  pump, 
-or  to  a  faucet  which  admits  the  water  with  sufficient  force  to  send  it 
to  the  most  remote  corners. 


20 


CLINICAL   AND    OPERATIVE    GYNAECOLOGY 


Should  the  operation  not  be  performed  in  a  hospital,  the  room 
chosen  should  be  carefully  prepared  at  least  two  days  in  advance. 
The  furniture  must  be  removed;  if  the  walls  have  not  been  newly 
whitewashed,  they  must  be  carefully  cleaned,  as  well  as  the  ceiling,, 
floor,  and  woodwork,  with  cloths  soaked  in  a  carbolic  solution 
50:1.000.     If  the  house  be  old,  or  the  room  under  suspicion,  this. 


fl-t: 


Fig.  13.— Collins1  Rotary  Atomizer. 


cleansing  should  be  supplemented  by  a  disinfection  with  sulphurous:, 
acid— placing  some  sulphur  (two  pounds  to  each  1,000  feet)  upon  a 
dish  in  the  middle  of  the  room,  setting  fire  to  it,  and  hermetically 
sealing  the  openings  to  the  chamber  during  twenty-four  hours. 

During  the  whole  of  the  operation  the  temperature  of  the  room 
should  be  high,  in  order  to  avoid  all  chilling  of  the  patient  intus 
et  extra.     From  77°  F.,  at  least,  to  86°  F.,  at  most,  is  necessary.     That 


ANTISEPSIS   lis    GYNECOLOGY.  21 

this  be  not  a  dry  heat — which  would  be  harmful  to  the  exposed  vis- 
cera— the  atmosphere  should  be  saturated  with  the  vapor  of  carbolized 
water  by  means  of  an  atomizer.  This  spray  should  not  be  directed 
npon  the  operating  held,  as  used  to  be  done  in  the  early  days  of  Lis- 
terian  antisepsis  and  as  many  operators  still  persist  in  doing.  The 
stream  of  vapor  should  be  directed  to  the  middle  of  the  room  with  an 
upward  and  downward  motion.  The  only  result  to  be  aimed  at  is  the 
saturation  of  the  atmosphere.  As  soon  as  this  is  accomplished,  the 
process  is  stopped,  and  repeated  only  if  the  length  of  the  operation 
renders  it  necessary.  Collins'  revolving  atomizer  perfectly  meets  the 
conditions.  A  spray  constantly  directed  toward  the  patient  is  more 
injurious  than  useful;  it  chills  and  irritates  the  peritoneum,  to  say 
nothing  of  the  dangers  of  intoxication.25 

Instruments. — These  should  have  been  cleaned  and  immersed  in 
foiling  water  for  five  or  ten  minutes  after  the  preceding  operation. 
On  the  day  appointed  for  the  laparatomy,  they  are  to  be  placed  for 
an  hour  in  a  sterilizing  oven  at  250°  to  290°  F.  (Fig.  14),  then  dropped 
into  the  carbolic  solution  50: 1,000.  Cutting  instruments  subjected  to 
-this  process  quickly  deteriorate,  and  need  to  be  constantly  sharpened. 

I  strongly  recommend  the  operator  to  use  his  own  and  never  bor- 
rowed instruments,  since  you  can  only  feel  perfectly  secure  in  regard 
to  the  disinfection  of  the  former.  Better  a  disinfected  bistoury  tha*fc 
is  dull,  than  a  sharp  bistoury  capable  of  infecting  the  patient. 

For  the  same  reason  I  have  given  up  the  use  of  sponges.  It  is  not 
-always  easy  to  obtain  new  and  perfectly  purified  sponges,  nor  need 
we  wonder  at  this  when  we  recall  the  elaborate  preparations  which 
they  must  undergo  before  they  can  be  called  clean.1  Sponges  which 
have  already  been  used  require  even  more  scrupulous  purification, 
and  are  less  to  be  trusted,  because  of  the  septic  fluids  which  may 
riave  contaminated  them.  So  that  sponges  are  both  unreliable  and 
expensive.  It  may  surprise  you  that  I  should  mention  expense  as 
worthy  of  consideration,  but  in  a  hospital  it  should  be  taken  into  ac- 
count. Finally,  it  often  happens,  especially  in  places  remote  from  the 
centres  of  trade,  that  one  has  at  hand  only  sponges  which  are  too 
Tough  to  use,  or  too  easily  torn,  of  an  inconvenient  size  or  shape,  and 
quite  unmanageable.  Having  been  a  witness  in  Billroth's  service  in 
Yienna  to  the  advantages  offered  by  the  antiseptic  gauze-sponges,  I 
use  them  to  the  exclusion  of  all  others.  This  is  my  method  of  pre- 
paring them :  a  piece  of  gauze  is  folded  several  times  in  such  a  way  as 
-to  make  pieces  twelve  inches  square,  composed  of  eight  thicknesses 


22  CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 

of  the  gauze.  These  compresses  are  hemmed  at  the  edges,  and  then 
boiled  for  at  least  two  hours  in  either  a  carbolic  solution  50:1,000  or 
bichloride  1 : 1,000.  They  are  then  kept  in  fresh  solutions  of  the  same 
composition,  which  should  be  renewed  weekly.  When  you  wish  to 
use  these  compresses,  they  are  to  be  caref  ally  washed  in  water  steril- 
ized by  filtration  and  boiling,  and  then  wrung  out.  They  now  consti- 
tute a  powerful  and  convenient  means  of  absorption,  which  can 
quickly  assume  any  shape  or  size,  which  can  cap  the  finger  to  pene- 
trate into  cavities  and  interstices,  which  can  be  spread  out  upon  the 
intestines,  in  short,  which  are  in  every  way  superior  to  sponges. 
During  an  operation,  a  compress  may,  if  necessary,  be  used  more 
than  once,  after  washing  it.  Those  which  have  been  soiled  by  septic 
fluids  are  thrown  away.  After  an  operation  all  are  destroyed — a 
process  fully  justified  by  the  low  price  of  their  manufacture,  but 
which  often  seems  an  extravagance  in  the  case  of  sponges.  About 
three  years  ago,  I  first  introduced  the  exclusive  use  of  gauze-sponges 
for  laparatomies,  and  detailed  their  advantages  in  a  report  to  the 
Surgical  Society,  October  19th,  1887  {Bull,  de  la  Soc.  de  Chir.,  Vol. 
XIII.,  p,  576).  Terrillon  has  recently  followed  my  example  by  ex- 
tolling their  merits;  Harteloup  has  also  adopted  them.  I  feel  sure 
that  any  opposition  to  them  will  be  of  short  duration,  and  that  they 
will  soon  be  in  general  use. 

As  regards  the  antiseptic  procedures  forming  a  part  of  the  opera- 
tion itself,  I  shall  content  myself  with  a  brief  examination  of  them, 
since  I  shall  return  to  the  subject  under  the  head  of  each  'special 
operation.     I  shall  here  mention  only  those  of  particular  importance. 

Care  of  the  Peritoneum. 

Laparatomists  have  long  pushed  to  an  extreme  the  care  taken  tc* 
clear  away  all  discharges  aud  clots  of  blood  from  the  peritoneum. 
They  have  greatly  exaggerated  the  noxious  action  of  these  residua, 
which  are  very  likely  to  be  reabsorbed  if  the  absorptive  powers  of 
the-  serous  membrane  are  not  destroyed  by  lotions  and  untimely  rub- 
bings. One  should  be  very  cautious  in  the  care  of  the  peritoneum 2T 
and  try  to  avoid  the  necessity  for  much  dressing  by  preventing  the 
overflow  of  the  contents  of  tumors.  Where  this  is  not  possible,  the 
cleansing  should  be  rapidly  accomplished  by  means  of  the  gauze- 
sponge.  According  to  many  authorities,  some  fluids  which  have  the 
reputation  of  being  very  infectious,  as  the  contents  of  cysts  and  the 


ANTISEPSIS   IN   GYNECOLOGY.  23 

pus  from  a  pyo-salpinx  of  long  standing,  are  really  less  dangerous  than 
has  been  supposed. 

Flushing  the  peritoneum  with  warm  sterilized  water  (to  which  I 
add  6  : 1,000  of  sodium  chloride)  was  first  extolled  by  Lawson  Tait, 
and  is  chiefly  of  use  where  an  irritating  or  infectious  fluid  has  come 
in  contact  with  the  serous  membrane  during  the  operation;  but  it 
should  not  be  used  to  wash  away  the  blood,  as  this  can  be  accomplished 
perfectly  well  by  means  of  the  gauze-sponges.  Although  it  is  cer- 
tainly a  serious  matter  to  leave  the  least  drop  of  pus  or  the  smallest 
septic  particle  in  the  peritoneal  cavity,  the  case  is  not  the  same  with 
small  clots  which  are  easily  absorbed.  There  is  another  indication 
for  these  hot-water  flushings  to  which  I  will  make  only  a  passing 
allusion.  They  have  been  much  praised  for  the  counteraction  of 
shock28  following  an  operation.  Polaillon29  has  recently  pointed  out 
the  danger  attending  the  administration  of  washings  of  too  high  a 
temperature  upon  the  supra-umbilical  portion  of  the  peritoneum  in 
the  vicinity  of  the  solar  plexus ;  they  may  cause  an  arrest  of  respira- 
tion and  syncope.  As  for  pelvic  washings,  they  are  not  harmful  when 
performed  rapidly  and  with  some  harmless  fluid  which  can  be  ab- 
sorbed without  danger.  However,  the  experiments  of  Delbet 30  have 
proved  that  these  washings  temporarily  impair  the  absorbing  powers 
of  the  peritoneum — a  fact  which  should  be  kept  in  mind  if  there  is 
any  fear  of  secondary  oozing,  as  it  may  render  drainage  necessary. 

Water  filtered  through  the  Chamberland  filter  may  still  contain 
microbes,  as  Tripier31  has  shown,  and  we  know  that  simply  boiling  it 
kills  the  germs  but  not  the  spores.  Certainly  water  which  has  been 
filtered  and  boiled  is  fairly  pure  and  may  be  used  without  much  fear. 
But*  to  insure  absolute  security  the  temperature  must  have  been 
raised  to  250°  F.  This  is  the  method  recommended  by  Tripier:  a 
glass  flask  is  provided  with  two  short  tubes  which  pass  through  the 
cork — one  of  these  tubes  has  an  enlarged  end,  which  is  filled  with 
cotton  to  filter  all  the  air  admitted  to  the  receptacle.  The  second 
glass  tube  is  adapted  to  a  rubber  tube  with  a  pinch-cock.  The  flask 
is  partly  filled  with  water,  which  must  not  be  reached  by  the  tubes, 
and  heated  to  250°  F.  in  the  Chamberland  steam  sterilizer.  The  flask 
is  removed  and  the  rubber  tube  adjusted,  and  one  has  only  to  tip  up 
the  flask  to  regulate  the  flow  of  water. 

I  propose  a  method  which  is  still  more  simple,  and  for  which  one 
can  use  an  ordinary  sterilizing  oven.  A  long-necked  flask  is  partly 
filled  with  water,  which  is  then  boiled,  and  as  soon  as  all  the  air  is 


24  CLINICAL    AND    OPERATIVE    GYNECOLOGY. 

displaced  the  neck  is  closed  by  fusion  over  a  lamp  liame.  The 
flask  can  now  be  placed  in  an  ordinary  sterilizer  and  submitted  to  a 
temperature  of  250°  F.  without  fear  of  seeing  all  the  water  pass  away 
into  steam,  which  would  be  the  case  had  not  the  neck  been  sealed. 
[As  the  tension  of  aqueous  vapor  at  250°  F.  is  about  two  atmospheres, 
the  evident  danger  of  exploding  the  flask  must  be  kept  in  mind. 
Practically,  carefully  filtered  and  boiled  water  is  sufficiently  aseptic] 
The  flask  can  then  be  kept  as  it  is,  or  the  neck  broken  and  filled  with 
a  cotton  tampon  to  filter  the  air  and  render  it  innocuous.  A  number 
of  flasks  can  be  prepared  and  kept  ready  for  use.  To  this  perfectly 
pure  water  can  be  added  salt  in  the  proportion  of  6 : 1,000,  and  it  is  now 
ready  for  use  in  washing  the  peritoneum,  or  for  injection  into  the  veins 
in  case  of  threatened  death  from  hemorrhage — a  means  which  has 
largely  taken  the  place  of  the  old-fashioned  transfusion  of  blood. 
The  cauterization  of  wounded  surfaces,  pedicles,  and  adhesions  has 
been  done  by  means  of  antiseptics  such  as  a  concentrated  solution  of 
carbolic  acid,  the  tincture  of  iodine,  iodoform,  or  with  the  actual  cau- 
tery. The  last-named  process  was  introduced  by  Baker-Brown,  and 
is  much  in  vogue  in  England  and  America.  For  my  part,  I  often  use 
it  where  a  cut  surface  has  a  suspicious  appearance  (as  in  some  salpin- 
gotomies) or  is  merely  thick  and  moist.  Be  it  understood,  I  speak  in 
this  connection  only  of  the  antiseptic  powers  of  cauterization,  which 
it  is  important  to  keep  separate  from  its  hemostatic  properties,  so 
valuable  in  parenchymatous  oozing.  Paquelin's  thermo-cautery  has, 
with  us,  taken  the  place  of  Baker-Brown's  red-hot  iron.  A  strip  of 
iodoform  gauze  should  be  wrapped  about  the  handle  of  the  instru- 
ment in  order  to  prevent  the  hands  from  becoming  soiled  by  contact 
with  it. 

Preparation  and  Preservation  of  Materials  Used  for 
Ligation  and  Suture. 

The  subject  of  antisepsis  in  gynecology  would  be  incomplete  with- 
out a  section  relating  to  the  preparation  and  preservation  of  the  vari- 
ous materials  used  for  ligatures  and  sutures. 

Silk. — The  strongest  with  the  least  bulk  is  the  flat  braided  silk,  of 
which  six  different  numbers  are  obtainable.  It  is  to  be  arranged  in 
very  loose  skeins  to  insure  a  perfect  disinfection  of  every  part,  boiled 
in  a  carbolic  solution  50:1,000,  wound  upon  glass  reels  and  immersed 
in  a  fresh  carbolic  solution  of  the  same  strength,  which  is  to  be 
changed  every  week.     It  is  well  not  to  prepare  too  much  silk  at  a 


ANTISEPSIS    IN    GYNECOLOGY.  25 

time,  for  it  is  most  reliable  immediately  after  the  boiling.  Hegar 
rises  an  iodoform  silk.  He  immerses  it  for  twenty-four  hours  in 
iodoform  ether  (20  grams  iodoform  to  200  grams  of  ether),  dries  it, 
winds  it  on  bobbins,  which  are  dusted  with  powdered  iodoform  and 
kept  in  glass  boxes.  Silk  may  also  be  rendered  antiseptic  by  boiling 
in  a  bichloride  solution  1 : 1,000.  Nilsen 32  suggests  that  wherever  silk 
is  to  be  used  for  sutures  or  ligatures  exposed  to  the  action  of  the  air, 
it  should  be  boiled  in  wax  and  carbolic  acid ;  this  would  render  it  im- 
permeable and  aseptic  at  the  same  time. 

For  my  part,  in  laparatomies,  I  prefer  to  use  the  carbolized  silk, 
with  which  there  is  less  risk  of  inducing  symptoms  of  poisoning 
where  one  is  obliged  to  use  many  ligatures  and  to  leave  them  in  the 
abdomen.  Some  enfeebled  patients  are  peculiarly  susceptible  to  mer- 
curial poisoning. 

Catgut. — In  preparing  catgut,  I  have  obtained  the  best  results  with 
the  oil  of  juniper  wood  (oleum  ligni  juniperi)  which  must  not  be 
confounded  with  the  oil  of  juniper  berries.  This  was  first  recom- 
mended by  Thiersch  and  then  adopted  by  Kiister,  Schroder,  Martin, 
Hofmeier,  etc.  Kocher  found  by  experimentation  that  this  oil  steril- 
izes violin-string  in  twenty-four  hours  (Troisfontaines,  "Manuel 
d'Antisepsie  Chirurg.,"  p.  100).  This  same  surgeon  has,  however,  lately 
decried  the  use  of  catgut,  holding  it  responsible  for  septic  accidents 
occurring  in  his  clinic.  It  seems  likely  that  Kocher  was  supplied 
with  a  bad  quality  of  catgut,  and  that  his  condemnation  is  too  sweep- 
ing.33 After  keej)ing  the  rolls  of  catgut  for  an  hour  in  an  aqueous 
solution  of  bichloride  1 : 1,000,  I  put  them  into  the  oleum  juniperi  for 
at  least  eight  days ;  they  are  then  removed  and  preserved  in  rectified 
spirits  to  which  is  added  a  tenth  part  of  the  juniper  oil.  Just  before 
using  the  catgut  is  put  into  watery  sublimate  solution,  which  swells 
it  a  little  but  renders  it  very  flexible.  Martin's  process  varies  slightly 
from  this.  The  catgut  is  rolled  on  the  glass  reels,  immersed  for  six 
hours  in  the  one-thousandth  solution  of  sublimate,  withdrawn,  dried 
by  pressing  in  a  towel,  and  placed  in  a  mixture  consisting  of  two 
parts  alcohol  and  one  part  oleum  juniperi.  This  may  be  used  with 
perfect  security  after  a  delay  of  six  days.  During  the  operation  the 
amount  to  be  used  is  kept  in  a  basin  filled  with  some  antiseptic  solu- 
tion. In  the  Frauenklinik  in  Berlin,  the  catgut  is  left  for  twenty- 
four  hours  in  oil  of  juniper,  then  for  twenty-four  hours  in  glycerin, 
and  finally  in  absolute  alcohol  to  which  is  added  a  small  amount  of 
the  oil. 


26 


CLINICAL   AND    OPERATIVE    GYNAECOLOGY, 


The  advantages  possessed  by  catgut  prepared  in  juniper  oil  are 
many ;  it  is  far  superior  to  that  more  commonly  used  which  is  disin- 
fected in  carbolized  oil;  it  possesses  remarkable  tenacity  and  flexi- 
bility; it  maybe  used  for  buried  sutures,  as  it  is  dissolved  and  ab- 
sorbed in  a  length  of  time  proportunate  to  its  bulk,  which,  by  the  wayr 
should  be  carefully  noted  by  the  operator.  It  is  because  of  these 
qualities  possessed  by  catgut  that  buried  sutures  and  sutures  in  layers, 


Fig.  14.— Wiesnegg's  Sterilizing  Oven.    A,  Regulator;  B,  burners;  C,  thermometer. 


have  been  undertaken  with  such  success  and  have  given  such  excel- 
lent results. 

Auguste  Reverdin34  has  proposed  a  further  technical  improve- 
ment, which  seems  to  me  to  be  destined  to  render  good  service.  He 
leaves  the  catgut  for  four  hours  in  a  sterilizing  oven  at  284°  F.  before 
putting  it  into  the  oil  of  juniper  and  alcohol.  He  advises  one  to  be 
sure  in  the  first  place  that  the  catgut  has  not  been  oiled  by  the  man- 
ufacturer for  purposes  of  preservation.  In  any  case,  I  think  it  well  to 
remove  all  grease  with  ether,  before  submitting  it  to  any  other  proc- 


ANTISEPSIS    IX    GYNAECOLOGY. 


27 


ess.  Benckiser,35  who  lias  adopted  the  method  of  disinfection  by  heat, 
places  his  rolls  of  catgut  in  envelopes,  before  putting  them  in  the 
sterilizer — opening  the  envelope  only  at  the  very  moment  of  using  the 
catgut. 

Many  surgeons  prefer  to  disinfect  the  catgut  with  carbolic  acid  or 
corrosive  sublimate.    The  following  method  is  that  used  in  Berg- 


Fig  15.— Glass  Reel  for  Silk  or  Catgut. 


mann's  clinic.36    The  gut  is  immersed  for  ten  to  fourteen  days  in  the 
following  solution  which  is  renewed  from  time  to  time : 


Hydrargyri  bichloridi, 

Alcoholis, 

Aquae  destillata?, 


1. 

800. 
200. 


J.  L.  Championniere,  following  Lister's  plan,  macerates  the  catgut 
in  this  mixture: 


Acidi  carbolici, 

Aquas, 

Olei  olivse,    . 


.  20. 
.  21. 
.     100. 


Fig.  16.— Reels  for  Silk  or  Catgut. 


The  carbolic  acid  is  dissolved  in  the  water,  then  emulsified  with  the 
oil  by  vigorous  shaking.     It  takes  five  or  six  months  of  maceration  to 


28  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

produce  a  well-prepared  catgut  and  even  then  it  is  oily  and  disagree- 
able to  handle. 

Mikulicz  has  indicated  a  method  of  preparation  which  transforms 
the  catgut  into  a  remarkably  resistant  and  tenacious  material  for 
sutures,  which  Leopold  has  adopted  for  Csesarean  sections.  The  cat- 
gut is  first  put  for  forty-eight  hours  in  carbolized  glycerin,  10  parts 
to  100,  then  for  five  hours  in  a  solution  of  chromic  acid  1 :  200,  and 
finally  preserved  in  absolute  alcohol.37 

Silver  Wire,  Silk-worm  Gut. 

After  heating  to  250°  F.  in  a  sterilizer,  these  may  be  preserved  in 
rectified  spirit. 

Drainage  Tubes.    Elastic  Ligatures. 

These  may  be  made  relatively  pure  by  leaving  them  for  ten  min- 
utes in  boiling  water,  and  then  preserving  them  in  strong  carbolic 
water,  or  in  a  sublimate  solution,  in  bottles  with  tightly-fitting 
corks.  Their  absolute  disinfection  is,  however,  not  assured  by  this 
process,  for  this  temperature  and  these  solutions,  while  doubtless  suf- 
ficing to  destroy  germs,  leave  the  spores  unaffected.  It  is  imprac- 
ticable to  leave  rubber  in  the  sterilizer  at  250°  F.,  because  heat  spoils 
it.  Therefore  we  have  recourse  to  a  roundabout  method.  We  pro- 
mote the  germination  of  spores  in  order  to  destroy  them  later.  This 
is  done  by  leaving  the  rubber  objects  for  five  days  in  water  which  is 
kept  at  about  95°  F.  in  a  culture  oven,  renewing  the  water  daily. 
After  this  process  they  are  to  be  placed  in  a  solution  of  corrosive 
sublimate  or  carbolic  of  50: 1,000,  which  is  to  be  changed  every  second 
day  for  the  first  fortnight.  At  the  end  of  this  time  they  may  be  used 
with  absolute  security. 

BIBLIOGRAPHY. 

1.  A.  von  Eiselsberg:  Ueber  den  Keimgehalt  von  Seifenund  Verbandmaterial. 
Wiener  med.  Wochensehr.,  Kos.  19,  20,  and  21,  1887. 

2.  Ftirbringer:  Zur  Desinfection  der  Hande.  Deutsche  med.  Wochensehr.,  1889, 
No.  48. 

3.  Landsberg:  Inaug.  Dissert.,  Vienna,  1888. 

4.  Davidson:  Wie  soil  der  Arzt  seine  Instrumente  desinficiren?  Berlin,  niedic. 
Woch.,  1888,  No.  35. 

5.  See  discussion  Soc.  de  Gyn£c.  de  St.  Petersburg.  Cent,  fur  Gyn.,  1887,  page 
■100. 


.     ANTISEPSIS    IX    GYNAECOLOGY.  20 

6.  Mijulieff:  M6moire  hollandais  analyzed  in  Centralbl.  f.  Gyniik.,  No.  35, 1887. 
Schrader:  Berichte  und  Arbeiten  aus  der  geburtshilflich-gynakologischen  Klinik 
zu  Marburg,  von  Ahlfeld;  Bd.  ii.,  p.  180.  Hoffmann  :  Die  Verwendung  des  Sub- 
limate als  Desinficiens  in  der  Geburtshilfe,  Marburg,  1886.  Keller:  Zur  Sublimat- 
frage.  Archiv  f.  Gynak.,  Bd.  xxvi.,  p.  107.  Doleris  et  Butte:  Recherches  Exp6ri- 
mentalessurlTntoxication  parle  Sublime.  Nouvelles  Annalesd'Obst.  et  de  Gynec.r 
No.  12,  1S86.  Otto  von  Herff:  Revue  critique.  .  Centralblatt  fiir  Gynak.,  No.  36, 
1887. 

7.  Briggs:   Sacramento  Medic.  Times,  No.  2,  1887. 

8.  Laplace:  Saure  Sublimatlosung  als  desinflcirendes  Mittel  und  ihre  Verwen- 
dung in  Verbandstoffen.     Deutsche  medic.  Wochenschrift,  No.  40,  1887. 

9.  Baumm:  Das  Creolin  in  der  Geburtshtilfe.  Centr.  f.  Gynak.,  1888,  No.  20. 
Born:  Erfahrungen  iiber  das  Creolin,  ibid.  About  creolin  consult  also  the  follow- 
ing papers:  A.  Weber:  Bulletin  medical,  1888,  No.  71.  A.  Heydenreich:  Semaine 
medicale,  Nov.  7th,  1888.  Roux:  Revue  medicale  de  la  Suisse  Romande,  1889,  No. 
0.     H.  J.  Garrigues:   The  American  Journal  of  Medical  Sciences,  August,  1889. 

10.  J.  Reverdin:   Rev.  Med.  de  la  Suisse  Romande,  Nov.,  1888. 

11.  Kaltenbach:  Zur  Antisepsis  in  der  Geburtshtilfe.  Sammlung  Yolkniann- 
scher  Yortrage.  No.  295. 

12.  Winter:  Die  Mikroorganismen  im  GenitalkanaldergesundenFrau.  Zeitsch. 
f.  Geburtsh.  und  Gynak.,  Band  xiv..  Heft  2. 

13.  Steffeck:  Ueber  Desinfektion  des  weiblichen  Genitalkanals.  Centr.  f. 
Gynak.,  188 3,  No.  28. 

14.  L.  Tripier:  De  la  Sterilisation  du  Coton,  de  la  Gaze  et  de  l'Eau.  Le  Prog. 
Med..  Dec.  3d,  1887. 

15.  Heyn  and  Rosving:   Fovtsch.  d.  Med.,  No.  2,  1887. 

16.  Litbbert:  Biologische  Spaltpilzuntersuehung,  1886. 

17.  C.  B.  Tilanus:   Miinchner  med.  Wochenschrift,  No.  17,  1887. 

18.  Behring:  Deutsche  med.  Wochenschrift,  No.  20,  1887.  Compare  also: 
Bramann:  Ueber  Wundbehandlung  mit  Iodoformtaniponade.  Archiv  f.  klin. 
Chirurg.,  Bd.  xxxvi.,  p.  77. 

19.  Sehlange  :  Ueber  sterile  Verbandstoffe.  Archiv  f.  klin.  Chir.,  1888,  Bd. 
xxxvi.,  Heft  4. 

20.  Bramann:   see  18. 

21.  Y.  Hacker:  Notice  sur  les  Precedes  antisept.,,  etc.,  trad,  par  J.  Redard. 
Revue  de  Chirurgie,  1884. 

22.  LawsonTait:  British  Medical  Journal,  April  15th  and  October  28th,  1882. 
The  Pathology  and  Treatment  of  Diseases  of  the  Ovaries,  4th  Edit.,  Birmingham,. 
1883,  p.  268  et  seq.     Bantock:   Medico-chirurgieal  Transactions,  vol.  lxiv. 

23.  H.  Yarnier:   Annales  de  Gynec,  1887,  p.  275. 

24.  Sanger:  Obst.  and  Gyn.  Society  of  Leipsic,  Jan.  21st,  1887.  Centr.  f.  Gyn.T 
1889,  No.  25.  J.  Yeit:  Obst,  and  Gyn.  Society  of  Berlin,  April  26th,  1889.  Centr.  f. 
Gyn.,  1889,  No.  21. 

25.  Hegar  and  Kaltenbach  :  Die  Operative  Gynakolo^  e,  1881,  p.  192  et  seq. 
Breisky:  Allg.  Wiener  med.  Zeitung,  1882,  No.  28.  Daniels  :  Buffalo  Med.  and 
Surg.  Journal,  June,  1882,  p.  512.     Yincent:   Revue  de  Chirurgie,  1881,  p.  516. 

26.  Terrier:  Preparation  des  Eponges  pour  les  Operations  Interessant  TAbdo- 
men.     Bull,  de  Soc.  de  Chir.  de  Paris,  page  92,  1886. 

27.  See  Discussion  Berlin  Obst.  and  Gyn.  Soc;   Cent.  f.  Gyn.,  No.  24,  18S8. 

28.  Wylie:   Medical  Record,  March  19th,  1887. 

29.  Polaillon:  Sur  un  Danger  du  Lavage  du  Peritoine.  Bull.  Acad,  de  M6d., 
August  28th,  1888. 

30.  Delbet:   Bull,  de  FAcad.  de  MeU,  June,  1889. 


30  CLINICAL    AND    OPERATIVE    GYNAECOLOGY. 

31.  Tripier:  De  la  Sterilisation  de  l'Eau  Destinee  au  Panseinent  des  Plaies. 
Progres  medical,  July  14th,  1888. 

32.  Nilsen:   Am.  Jour,  of  Obstetrics,  1888,  page  308. 

33.  Kocher:  Correspblatt.  i'tir  Schw.  Aerzte,  ~So.  1,  1888,  and  Zweifel:  Die 
Stielbehandlung,  etc.,  page  51;  also  J.  L.  Championniere,  Bull,  de  la  Soc.  Chir.  de 
Paris,  xiv.,  page  51. 

34.  Aug.  Reverdin:  Recherches  sur  la  Sterilisation  du  Catgut.  Revue  medicale 
-de  la  Suisse  Romande,  ]Nos.  6,  7,  and  9,  1888. 

35.  Benckiser  :   Ueber  steril.  Katgut.     Centrbl.  f.  Gyn.,  1889,  IS'o.  31. 

36.  Bramann  :   Arch.  f.  klin.  Chir.,  1887,  xxxvi.,  p.  75. 

37.  Thomson:  Experiment elle  Untersuchungen  iiber  die  gebrauchlichsten  ]Sah- 
3Iateriale  bei  intraperitonealen  Operationen.     Centr.  f.  Gyn.,  1889,  ]So.  24. 


CHAPTER  II. 
ANESTHESIA    IX    GYNECOLOGY. 

Local  anaesthesia  may  often  be  employed  with  good  results,  the 
method  differing  according  to  whether  the  operation  be  upon  the  skin 
or  mucous  membrane.  For  an  incision,  or  a  rapid  dissection,  we  may 
freeze  the  part  by  means  of  a  mixture  of  cracked  ice  and  salt,  operat- 
ing the  very  moment  the  skin  becomes  white,  for  an  undue  prolonga- 
tion of  the  action  of  the  cold  might  result  in  a  blister  or  even  a  slough. 
Kichardson's  ether  spray  is  exceedingly  convenient  and  too  well 
known  to  need  description.  It  possesses  the  drawback  of  slow  action 
and  of  preventing  the  use  of  the  thermo-cautery;  some  foreign  au- 
thorities, and  Terrillon :  in  France,  have  proposed  replacing  it  with  a 
spray  of  bromide  of  ethyl,  which  is  non-inflammable ;  but  this  in  its 
turn  possesses  disadvantages  which  have  interfered  with  its  wide- 
spread use. 

Cocaine  chlorhydrate  can  be  used  for  anaesthesia  of  the  skin. 

"Worfler 2  has  demonstrated  that  if  you  inject  hyi3odermatically,  or 
preferably  endermatically,  fifteen  minims  of  a  five-per-cent  solution, 
at  the  end  of  one  or  two  minutes  a  local  anaesthesia  will  be  produced 
which  will  last  from  twenty  to  twenty-five  minutes.  The  zone  of- 
anaesthesia  will  extend  about  two  to  three  centimetres  around  the 
point  of  entrance,  and  a  second  area  of  semi-anaesthesia  of  the  same 
extent  surrounds  the  first — which  gives  us  from  four  to  six  square 
centimetres  upon  which  Ave  may  operate  painlessly  for  from  twenty 
to  twenty-five  minutes.  This  is  more  time  than  is  needed  to  open  an 
abscess  or  remove  a  small  tumor.2  If  the  operation  is  to  be  upon  a 
mucous  surface,  all  that  is  required  is  to  paint  it  over,  with  a  ten- 
per-cent  solution  of  the  cocaine.  This  will  produce  an  anaesthesia 
which  may  easily  be  prolonged  by  repeated  applications,  so  that,  as 
I  can  bear  testimony  from  my  own  experience,  an  Emmet's  ampu- 
tation of  the  cervix  may  be  done  by  this  means.  The  anaesthetized 
mucous  surface  seems,  to  use  the  patient's  own  expression,  to  be 
"made  of  wood." 

I  am  convinced  that  the  field  of  local  anaesthesia  in  gynaecology 


32  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

would  be  greatly  increased,  could  we  but  overcome  the  timidity  of 
those  patients  whose  fears  yield  more  readily  to  general  anaesthesia.3 
Daniel  Lewis,4  of  New  York,  after  the  injection  of  cocaine,  performed 
a  painless  amputation  of  the  breast  upon  a  woman  of  sixty  years, 
Mho,  on  account  of  a  cardiac  murmur,  was  in  dread  of  general  anaes- 
thesia. In  the  same  way  I  amputated  the  finger  of  a  young  woman 
who  absolutely  refused  to  be  made  unconscious. 

We  must  not  omit  to  mention  and  inquire  into  the  statement 
made  by  Hanks,5  namely,  that  applications  of  cocaine  have  an  injuri- 
ous effect  upon  the  union  of  wounds  after  plastic  operations.  In  the 
cases  quoted  by  the  American  surgeon,  may  this  result  not  be  diie  to 
the  use  of  a  non-sterilized  cocaine  solution  ?  The  water  for  these  solu- 
tions should  be  distilled  and  then  boiled,  and  it  is  well  to  add  a  few 
drops  of  Van  Swieten's  fluid.  Nevertheless,  we  should  bear  in  mind 
that  accidents  have  sometimes  occurred  as  a  result  of  these  injections, 
and  use  them  with  moderation.  Dudley 6  reports  to  the  Obstetrical 
Society  of  New  York  three  cases  where  the  hypodermatic  injection 
of  cocaine  was  followed  by  most  alarming  symptoms.  In  two  of  the 
cases  he  had  injected  a  solution  into  the  cervix  before  curetting  the 
uterus,  in  the  third,  at  the  margin  of  the  anus  before  removing  a 
syphilitic  growth.  He  used  a  ten-per-cent  solution,  of  which  he  in- 
jected about  fifty  minims.  One  of  the  patients  swooned;  all  were 
greatly  depressed.  Emmet  has  noted  similar  untoward  results.  A 
loss  of  consciousness  has  been  observed  after  the  hypodermatic  injec- 
tion of  six  drops  of  a  twenty-per-cent  solution  of  the  chlorhydrate  of 
cocaine,  which  is  equivalent  to  six  centigrams  of  the  active  principle.7 
Very  serious  symptoms,  such  as  vomiting,  extreme  weakness,  slowing 
of  the  respiration,  and  enormous  increase  in  the  pulse  rate,  resulted 
from  the  hypodermatic  injection  of  one  grain  (sixty-five  milligrams) 
with  which  Dr.  B.  J.  HowTel8  experimented  upon  himself.  It  would 
seem  to  be  unsafe  to  venture  upon  a  dose  larger  than  five  centigrams, 
or  twenty  drops  (about  a  gram^  of  the  five-per-cent  solution  of  hydro- 
chlorate  of  cocaine.  Reclus,9  unwisely,  in  my  opinion,  does  not  hesi- 
tate to  give  twenty  centigrams. 

Continuous  irrigation  which  is  so  useful  from  the  point  of  view  of 
convenience  and  antisepsis,  has  also  a  remarkable  power  of  diminish- 
ing pain,  especially  when  even  a  weak  solution  of  carbolic  acid  is  used 
(10  : 1,000). 

Finally,  in  extremely  nervous  or  hysterical  Avomen,  Ave  may  obtain 
sufficient  anaesthesia  by  means  of  hypnotic  suggestion.10     I  call  atten- 


ANAESTHESIA   IN"   GYNAECOLOGY.  S3 

tion  to  this  as  something  of  a  pathological  curiosity;  nevertheless,  at 
Lourcine-Pascal  I  have  several  times  been  enabled  to  curette  a  patient 
without  causing  pain,  by  simply  suggesting  that  she  was  not  suffer- 
ing, and  this  without  having  to  put  her  to  sleep.  Very  recently 
Gevl, "  of  Dordrecht,  was  able  to  excise  a  prolapsed  rectum  and  am- 
putate a  cervix  by  complete  anaesthesia  from  hypnotic  influence 
alone,  lasting  two  hours  in  the  first  case,  one  hour  in  the  second. 

Mesnet 12  reports  to  the  Academy  of  Medicine  a  case  of  vaginal 
cystocele  painlessly  operated  upon  under  the  same  conditions. 

General  anaesthesia  is  indispensable  in  major  operations;  it  may- 
even  be  used  in  slight  ones  if  administered  with  the  proper  precau- 
tions.    I  usually  employ  it  when  curetting  a  uterus. 

Finally,  when  an  examination  of  the  abdominal  organs  presents 
much  difficulty,  anaesthesia  is  a  necessity.  The  exploration  is  greatly 
facilitated  by  the  resulting  flaccidity  of  the  abdominal  walls  and  the 
absence  of  reflex  movements  caused  by  pain.  This  exploratory  anaes- 
thesia should  be  the  rule  in  many  procedures,  as  without  its  help  it  is 
often  imiDossible  to  obtain  an  exact  knowledge  of  the  condition  of  the 
uterine  appendages  where  these  are  inflamed.  Lawson  Tait,  Keith, 
and  other  English  operators  prefer  ether  to  chloroform,  claiming  that 
there  is  less  excitement  and  less  vomiting  from  its  use.  But  it  has 
been  charged  with  an  injurious  action  ux>on  the  renal  epithelium, 
which  would  contra-indicate  its  use  wherever  the  kidneys  are  affected, 
as  is  often  the  case  in  patients  with  abdominal  tumors. 

Lee,  Dudley,  Freeman,  and  Talbot13  have  instanced  such  cases. 

Many  German  laparatomists  use  a  mixture  of  chloroform  and  alco- 
hol; the  anaesthesia  is  said  to  be  more  uniform,  and  vomiting  less 
frequent.  In  France,  chloroform  reigns  almost  without  a  rival.  Its 
purity  should  always  be  tested,  especially  if  the  anaesthesia  is  to  be 
of  long  duration. 

Under  the  same  conditions  and  for  peculiarly  nervous  and  excita- 
ble patients,  I  have  found  it  advantageous  to  precede  the  administra- 
tion of  chloroform  with  a  hypodermatic  injection  of  one  and  a  half 
centigram  (twenty-five  to  thirty  drops)  of  this  solution: 

Distilled  water, 10.00 

Morphine  hydrochlorate,        ....    10.00 
Sulphate  of  atropine, 0.005 

This  should  be  given  fifteen  or  twenty  minutes  before  the  chloroform. 

The  resulting  unconsciousness  is  more  regular  and  of  longer  duration. 
3 


34  CLINICAL  AND   OPERATIVE   GYNAECOLOGY. 

although  much  less  chloroform  is  required,  and  it  also  makes  it  easier 
to  administer  the  anaesthetic  with  care.     This  process  of  mixed  anaes- 
thesia, which  we  owe  to  Dastre  and  Morat,  can  scarcely  be  awarded 
too  much  praise  in  ojjerations  of  any  considerable  length.     It  is  de- 
signed to  avoid  the  symptoms  due  to  chloroform  which  the  surgeon  is 
unable  to  combat— laryngo-reflex  syncope — especially  secondary  syn- 
cope.    It  prevents  the  initial  excitement,  diminishes  the  nausea,  limits 
the  amount  of  chloroform  used,  and  consequently  lessens  the  chances 
of  chloroform  poisoning  in  operations  of  long  duration.14     My  learned 
friend,  Professor  Dastre,  has  assured  me  that  in  his  laboratory  exper- 
iments, before  he  adopted  this  method,  he  lost  one  out  of  every  four 
dogs  anaesthetized.     For  the  past  ten  years  (1879-1889)  he  has  used 
it  upon  hundreds   of   animals,  and  has  not  lost   one.     Safety  and 
convenience  are  both  gained  by  the  process.     It  has  been  adopted 
by  practical  surgeons.     Aubert,  head  surgeon  of  the  Antiquaille  in 
Lyons,  uses  it  to  the  exclusion  of  all  other  methods,  and  testifies  to 
its  value  in  these  words   (C.  R.  Soc.  Biol.,  21st  April,  1883,  p.  282): 
"  I  know  of  nothing  better  nor  more  practicable.     This  method  has 
the  following  advantages:    1.  Safety.     2.  More  rapidly-induced  un- 
consciousness.    3.  Absolute  calm  on  the  part  of  the  patient.    4.  An 
easy  awakening.     5.   Very  little  malaise  or  vomiting  as  sequelae. 
Many  of  my  colleagues  in  Lyons,  especially  Professors  Gayet  and 
Leon  Tripier,  have  at  my  instigation  used  this  method  of  anaesthesia. , 
The  number  of  cases  experimented  upon  (1887)  amounts  to  several 
thousands,  with  no  resulting  accident."    This  mixture  of  morphine 
and  chloroform  was  first  used  experimentally  as  an  anaesthetic  by 
Claude  Bernard  in  1864,  and  in  surgery  by  Nussbaum,  of  Munich. 
Further  researches  were  carried  on  by  Labbe  and  Guyon,  Guilbert  de 
Saint-Briene,  Labbe  and  Goujon  (1872).     The  combined  use  of  chloral 
and  chloroform  was  tried  by  Dr.  Forne  (1874)  and  Dr.  Dubois  upon 
alcoholic  patients.     Professor  Trelat  used  this  same  mixture  in  oper- 
ations when  the  patient  needed  only  to  be  slightly  stupefied  (4  to  9 
grams  of  chloral  hydrate  to  20  to  40  grams  of  the  syrup  of  morphine 
of  the  codex,  in  120  grams  of  water,  to  be  taken  in  two  doses  at  an 
interval  of  fifteen  minutes).     Lastly,  alcohol  has  been  combined  with 
chloroform  and  with  ether  (Dubois,  1876),  more  especially  in  alcoholic 
cases.15    The  patient  is  anaesthetized  in  bed,  and  taken  to  the  amphi 
theatre  in  a  ward-carriage  (Fig.  17),  thus  avoiding  the  disagreeable 
impression  produced  by  the  sight  of  the  surgical  preparations,  and 
facilitating  the  first  steps  in  the  administration  of  the  chloroform. 


ANAESTHESIA   IX   GYNAECOLOGY. 


35 


We  must  bear  in  mind  that  if  amesthesia  be  unduly  prolonged,  it 
may  have  a  serious  effect  upon  the  nervous  system  and  upon  the  kid- 
neys. The  fatal  results  of  many  cases  reported  under  the  head  of 
shock,  may  be  traced  to  the  depressing  effects  upon  the  nerve  cen- 
tres of  an  anaesthesia  prolonged  to  two  or  three  hours.  It  is  not  im- 
possible that  many  of  the  so-called  rellex  symptoms  occurring  after 
utero -ovarian  operations  may  be  due  to  the  same  cause;  more  partic- 
ularly what  has  been  termed  the  guttural-reflex  symptom,  character- 
ized by  incessant  and  painful  expectoration.16  1  have  had  the  oppor- 
tunity of  observing  this  symptom  after  long  operations  other  than 


Fig.  17.— Rolling  Carriage  Used  at  the  Lourcine-Pascal  for  Transporting  Patients  from  Bed 

to  the  Operating  Boom. 


-abdominal,  and  I  feel  convinced  that  it  is  due  to  real  chloroform- 
poisoning. 

Further,  the  absorption  of  a  large  quantity  of  chloroform  or  ether, 
and  its  consequent  elimination  by  the  kidneys,  may  determine  an  in- 
tense renal  congestion  with  or  without  albuminuria.  I  first  called 
attention  to  this  fact  in  a  work  published  in  the  Annales  de  Gyne- 
cologic in  July,  1884  ("De  la  valeur  des  alterations  du  rein  conse- 
cutives  aux  corps  fibreux  de  l'uterus  pour  les  indications  et  le  pronos- 
tic  de  l'hysterectomie  ").  This  is  what  I  wrote  at  the  time:  "  The  long 
duration  of  anaesthesia  in  operations,  especially  hysterectomies,  has 
doubtless  a  large  share  in  the  causation  or  aggravation  of  renal  affec- 
tions in  the  patient.  Chloroform  absorbed  in  great  amount  cannot 
iail  to  have  an  action  upon  the  renal  epithelium,  and  thus  interfere 


36  CLINICAL  AND   OPEEATIVE   GYNAECOLOGY. 

with  the  elimination  of  the  constituents  of  the  urine ;  this  action  may 
be  the  source  of  immediate  danger  when  there  is  a  pre-existing  lesion 
of  the  organ."  A  few  months  later,  Terrier,  at  a  meeting  of  the  Surgi- 
cal Society  held  on  the  17th  of  December,  1884,  presented  a  paper 
based  upon  the  analyses  of  his  pharmaceutical  interne  G.  Patein,  on 
the  presence  of  albumin  in  the  urine  after  the  administration  of 
chloroform;  he  read  a  second  paper  upon  the  same  subject  the  1st  of 
April,  1885.  Terrier  and  Patein,  from  the  most  exact  analyses  of  the 
urine  of  patients  who  had  ovariotomy  performed,  reached  the  follow- 
ing conclusions: 

1.  After  anaesthesia  alone,  the  number  of  cases  in  which  albumin 
is  found  is  about  doubled,  and  the  quantity  of  albumin  greatly  in- 
creased. 

2.  After  anaesthesia  plus  the  operation,  albuminuria  is  almost  the 
rule.  They  agree  with  Professor  Bouchard  in  attributing  this  albu- 
minuria to,  1st,  the  action  of  the  chloroform ;  2d,  the  operation,  which, 
excites  the  sensory  nerves.  This  albuminuria,  when  not  immediately 
fatal,  may  be  of  temporary  duration  (see  Patein's  Thesis,  Paris> 
1888:  "De  l'albuminurie  consecutive  aux  inhalations  chloroform- 
iques ").  This  undoubtedly  has  much  to  do  with  the  symptoms  of 
dyspnoea  which  have  been  known  to  follow  laparotomies.  It  is  espe- 
cially after  abdominal  hysterectomies  that  these  cardio-pulmonary 
symptoms  have  been  observed,  and  we  know  that  in  these  cases  the 
kidneys  are  peculiarly  vulnerable,  since  abdominal  tumors  in  general 
and  fibroids  in  particular  are  a  predisposing  cause  of  chronic  nephritis. 
The  renal  filter  is  then  in  a  defective  condition,  and  powerless  to  rid 
the  circulatory  current  of  the  toxic  agent  introduced  by  a  long  pul- 
monary absorption.  Moreover,  in  patients  with  abdominal  tumors, 
the  heart,  as  well  as  the  kidneys,  is  often  affected  (see  also  chapter- 
on  fibroma),  and  it  is  easy  to  comprehend  why,  in  these  persons,  a 
prolonged  anaesthesia  is  followed  by  certain  fatal  symptoms  whose 
pathogenesis  has  not  heretofore  been  thoroughly  understood.  I  have 
alluded  to  heart  lesions  as  frequently  complicating  abdominal  surgery. 
Granted  that  they  call  for  especial  precautions  as  to  the  duration  of 
anaesthesia,  do  they  absolutely  contra-indicate  the  administration  of 
chloroform  ?  In  France,  the  prevalent  opinion  is  that  they  do,  but 
according  to  the  greatest  English  authorities  on  ovariotomy,  they  do 
not.  The  latter  claim  that  in  chloroform  anaesthesia  fatal  results  are 
due  to  a  reflex  inhibition  of  the  cardiac  centres  or  of  the  respiratory 
and  vaso-motor  centres;  that  this  reflex  inhibition  is  most  apt  to 


ANESTHESIA   IN   GYNECOLOGY.  37 

occur  where  there  is  organic  disease  of  the  heart,  and  that,  therefore, 
paradoxical  as  it  may  seem,  it  is  in  reality  logical  to  administer  chlo- 
roform in  just  such  cases,  and  to  push  it  to  the  point  of  complete 
abolishment  of  reflexes.17  Fatty  degeneration  of  the  heart,  chronic 
renal  disease,  atheroma  of  the  arteries,  and  extreme  weakness  consti- 
tute absolute  contra-indications  to  the  use  of  chloroform. 

It  is  quite  unnecessary  to  give  details  upon  the  manner  of  admin- 
istering an  anaesthetic,  and  methods  of  resuscitation  in  case  of  acci- 
dent.    A  few  words  of  counsel,  however,  may  be  to  the  point. 

An  important  preliminary  precaution  is  the  removal  of  false  teeth 
and  plates.  The  face  should  be  anointed  with  oil  of  some  kind,  to 
prevent  the  irritating  effect  of  chloroform  during  prolonged  anaes- 
thesia. The  chloroform  itself  should  have  been  recently  purified, 
.and  kept  away  from  the  light;  the  required  amount  may  be  put,  just 
before  the  operation,  into  a  flask  provided  with  a  double  tube,  or  else 
with  a  cork  in  which  you  can  make  a  small  opening  to  limit  the 
amount  used.  Junker's  apparatus  is  much  used  in  other  countries ; 
in  France  we  prefer  to  use  a  folded  piece  of  linen,  a  simple  procedure, 
which  the  English  sometimes  describe  as  the  Scotch  method,  and 
which  allows  of  a  close  inspection  of  the  patient's  face.  It  should  be 
Iield  a  little  ways  from  the  nose  and  mouth,  and  in  order  to  prevent 
much  loss  of  chloroform  by  evaporation  as  well  as  to  make  the  com- 
press easier  to  handle,  it  is  well  to  cover  it  with  a  piece  of  oiled  silk. 

Wherever  practicable,  one  assistant  should  devote  himself  to  the 
administration  of  the  chloroform,  giving  it  in  small,  but  oft-repeated 
doses,  closely  watching  the  pulse  and  respiration. 

To  prevent  accidents,  note  the  respiration  and  the  pupils  even 
more  carefully  than  the  pulse ;  draw  the  tongue  forward  by  pressing 
upon  the  lower  jaw,  or  by  seizing  it  with  the  forceps.  Spring  forceps 
are  to  be  avoided,  as  they  produce  sloughing.  I  use  forceps  of  my 
own  devising  (which  Aubry  has  manufactured  for  me  for  ten  years) ; 
the  spatulated  blade  is  slipped  under  the  tongue,  and  the  two  sharp 
teeth  of  the  upper  blade  give  a  sure  hold  at  the  expense  of  very  slight 
wounds. 

Certain  circumstances  in  gynaecological  operations  call  for  especial 
care.  Respiration  is  embarrassed,  and  the  difficulties  of  anaesthesia 
increased,  when  the  patient  lies  upon  her  side  or  is  kept  in  the  genu- 
pectoral  position.  There  are  also  some  processes  connected  with 
laparatomies  during  which  the  dangers  of  anaesthesia  are  augmented; 
the  withdrawal  of  a  great  amount  of  fluid  or  of  a  large  tumor,  traction 


3S 


CLINICAL    AST)    OPERATIVE   GYNAECOLOGY. 


upon  the  pedicle  of  a  uterine  tumor,  or  upon  the  broad  ligament  may 
be  the  cause  of  reliex  action  upon  the  respiratory  or  circulatory  ap- 
paratus. Interference  with  respiration  due  to  a  mechanical  cause, 
such  as  the  accumulation  of  mucus  in  the  pharynx,  is  a  mere  incident 
and  not  an  accident,  easily  remedied  by  introducing  a  sponge  upon  a. 
holder,  pressing  it  firmly  and  deeply  and  removing  the  obstruction. 

Should  dyspnoea  supervene,  or  the  breathing  cease,  have  recourse 
at  once  to  artificial  respiration,  practised  slowly,  regularly,  persist- 
ently.    If  the  pulse  stop  suddenly  and  syncope  occur,  keep  the  head 


Fig.  IS.— Tongue  Forceps. 


dependent,  flagellate  the  surface  of  the  body,  sprinkle  cold  water 
upon  the  face  and  back  of  the  neck,  apply  electricity  to  the  phrenic 
and  pneuinogastric  nerves  and  perform  artificial  respiration.  Assist- 
ants should  take  turns  in  applying  this  last  means  of  resuscitation, 
which  I  have  seen  result  in  complete  recovery  at  the  end  of  twenty 
minutes.  Should  the  room  be  very  warm,  or  full  of  the  fumes  of  car- 
bolic acid,  it  must  be  freely  aired. 


BIBLIOGRAPHY. 

1.  Terrillon  :  Bull,  de  la  Soc.  de  Chir.,  1880,  pages  198,  213,  221,  261. 

2.  Wolfler  :  Leber  die  anasthesirende  Wirkung  der  subcutanen  Cocal'n-Injek- 
tionen.    Wien.  med.  Woch.,  1885,  No.  50. 

8.  Frankel :  Ueber  Coealn  als  Mittel  zur  Anasthesirung  der  Genital-Schleim- 
haut.  Centralblatt  f.  Gyn.,  1884,  p.  777.  Ueber  locale  Anasth.  bei  der  Perineo- 
plastik  dureh  subcutan.  Cocaln-Injektionen.     Centr.  f.  Gyn.,  1886,  No.  25. 

4.  Daniel  Lewis  :  Medical  Record,  June  4th,  1887. 

5.  H.  T.  Hanks  :  Obstet.  Soc.  of  New  York.  Amer.  Journal  of  Obstetrics,  xxi.,. 
p.  315. 

6.  Dudley  :   Obstet.  Soc.  of  New  York.     Amer.  Jour,  of  Obstet.,  xxi.,  p.  315. 

7.  Gazette  m£dicale  de  Paris,  April  24th,  1886. 

8.  J.  B.  Howell :  Medical  News,  1882,  p.  487. 

9.  Reclus  and  Wall :  La  Cocaine  en  Chirurgie  courante.  Revue  de  Chirurgie, 
February,  1889,  p.  149.  Delbosc :  De  la  Cocaine.  These  de  Paris,  1889.  Roux  : 
Revue  m6dicale  de  la  Suisse  Romande,  1889,  p.  55. 


ANESTHESIA    IN    GYNAECOLOGY.  3D 

10.  Guinon  :  Raclage  de  FUt6rus  sous  le  Soiiimeil  Hypnotique.  Gaz.  M6di- 
cale,  Paris,  April  16th,  1S87. 

11.  Geyl :  Ueber  scheinbare  Wirkung  des  Cocai'n.  Archiv  fur  Gynakol.,  1887, 
Bd.  xxxi.,  Heft  3. 

12.  Musnet :  Bull,  de  l'Acad.  de  Mt?deeine,  July,  1889. 

13.  Trans.  N.  Y.  Obst.  Soc.     American  Journal  of  Obstetrics,  1888. 

14.  The  numerous  theoretical  and  practical  questions  which  arise  in  this  con- 
nection, ai-e  discussed  in  the  two  following  papers  :  Sur  un  ProceY16  d'Anesthesie. 
C.  R.  de  la  Soci£t<5  de  Biologie,  7th  series,  vol.  v.,  p.  242,  April  7th,  1883;  Sur  le 
Procede  de  MM.  Dastre  et  Morat :  Anesthesie  Mixte  par  la  Morphine,  Atropine, 
Chloroforme.  C.  R.  Soc.  Biol.,  vol.  v.,  p.  29,  April  14th,  1883.  See  also  the  discus- 
sion of  the  subject  by  MM.  Francois  Franck,  Poncet,  Brown-S£quard,  Paul  Bert, 
Aubert. 

15.  Dastre  :  Etude  critique  des  Travaux  regents  sur  les  Anesth£siques.  Revue 
des  Sciences  Medicales,  1881.  E.  Bidot :  Des  Proc<5de"s  Mixtes  en  Anesth6sie,  etc. 
These  de  Paris,  1887. 

16.  J.  L.  Championniere  :  Des  Reflexes  Observes  apres  les  Operations  Ut£ro- 
ovariennes.     Annales  de  Gyne'cologie,  May,  1888,  p.  592. 

17.  Hart  and  Barbour :  Manual  of  Gynecology,  1886  ;  Qu£nu  and  Terrier  up- 
hold this  opinion. 


CHAPTER  III. 
METHODS   OF   SUTURE   AND   H^EMOSTASIS. 

Sutures. — Union  by  first  intention,  which,  with  a  few  exceptions 
for  special  cases,  has  become  the 'rale  in  modern  .snrgery,  is  of  prime 
importance  in  gynaecology;  npon  it  depend  the  success  of  plastic  and 
the  innocuousness  of  other  operations.  I  shall  not  dwell  ux>on  the 
local  conditions  necessary  to  such  union ;  the  cardinal  principles  are 
known  to  be  these:  that  the  wound  be  clean  cut,  its  surfaces  smooth, 
accurately  approximated,  and  without  dead  spaces,  that  no  traction 
be  exerted,  and  but  little  pressure  applied.  The  raw  surface  should 
be  thoroughly  pared  and  all  superfluous  tissue  removed  by  means  of 
curved  scissors ;  the  sutures  should  then  be  so  ajDplied  as  best  to  imi- 
tate the  normal  condition  of  the  tissues. 

Although  all  gynecologists  are  doubtless  familiar  with  the  ordi- 
nary rules  of  surgery,  it  will  be  well  in  this  connection  to  repeat  cer- 
tain points  of  especial  importance. 

The  needles  may  be  used  in  one  of  several  ways.  1st.  They  may 
be  held  in  the  fingers ;  this  is  extremely  inconvenient  and  should  be 
done  only  where  absolutely  necessary. 

2d.  Needles  immovably  attached  to  a  handle  are  used  in  passing 
through  resistant  tissues  or  parts  difficult  to  reach.  Deschamp's 
sharp-pointed  needle,  which  is  of  this  description,  may  be  used  to 
advantage  high  up  in  the  vagina,  upon  the  cervix  uteri,  or  in  the 
culs-de-sac,  but  where  the  needle  has  to  pass  through  relaxed  tissues 
rich  in  blood-vessels  (ovarian  pedicles,  round  ligaments,  etc.),  blunt 
needles  with  a  rounded  edge  will  push  aside  the  vascular  tissues 
without  wounding  them. 

I  have  already  said  that  grooved  needles  or  those  with  movable 
eyes  should  be  discarded  on  account  of  the  difficulty  of  keeping  them 
clean. 

3d.  The  needles  may  be  inserted  in  a  holder.  This  is  the  most 
usual  method. 

Three  kinds  of  needles  are  used:  ordinary  surgical  needles,  which 
are  flat  and  slightly  enlarged  near  the  point,  giving  them  a  lanceolated 


METHODS    OF   SUTURE   AND   HxEMOSTASIS. 


41 


appearance.  They  penetrate  the  tissues  with  ease,  but  make  a  trans- 
verse incision  which  is  drawn  upon  and  enlarged  when  the  sutures 
are  tied  (Fig.  20).  Curved  needles,  or  those  curved  near  the  point  are 
most  in  use, 


Fig.  19.— Largt:  Mounted  Needles.    1,  Emmet's,  Croft's,  orPean's;  2,  blunt  pointed ;  3,  blunt 
Deschamp"s;  4,  sharp  Deschamp's. 


Hagedorn's  flat  needles  (Fig.  21),  curved  on  the  edge  and  bevelled 
at  the  point,  possess  a  greater  cutting  power  than  the  old  surgical 
needles.     They  are  of  the  greatest  use  in  plastic  operations. 

One  should  have  on  hand  a  supply  of  needles  of  all  sizes :  very  fine 
ones  are  required  for  certain  plastic  operations,  as  in  vesico-vaginal 


42 


CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 


fistula? ;  while  for  suturing  the  abdominal  walls  after  a  laparotomy,  it 
is  well  to  have  needles  of  more  than  ordinary  strength  (Fig.  22).  The 
choice  of  a  needle-holder,  of  which  there  are  many  varieties,  depends 


Fig.  20. — Designed  to  Show  the  Superiority  of  thb  Flat  over  the  Ordinary  Needle,  a,  a,  Skin, 
■wounds  made  by  ordinary  surgical  needle;  6,  b,  enlargement  of  these  orifices  by  the  suture;  c,  c,  wounds- 
made  by  Hagedorn  needle  ( d,  d)  which  are  not  enlarged  by  the  suture. 

upon  whether   the    operation    demands   chiefly  great    accuracy  or 
strength.     If  the  former,  it  may  be  found  more  convenient  to  use  a. 


Fig.  21. — Hagedorn  Needles. 


Fig.  22.— Ordinary  Surgical  Needles  Made  Strong 
for  Suturing  the  Abdominal  Walls  after  Lapa- 
ratomy. 


lock-forceps,  which  obviates  all  necessity  of  keeping  the  needle  in 
place  by  pressure  on  the  handle,  and  allows  of  concentration  of  atten- 
tion upon  the  movements  of  the  needle.     Collin's  forceps  meet  this 


METHODS    OF    SUTURE    AND    HJE.UOSTASIS. 


43 


indication,  and  with  my  modification  will  hold  the  Hagedorn  needle. 
They  can  be  taken  apart  and  cleaned  (Fig.  23). 

If  thick  or  resistant  tissues  are  to  be  sutured,  larger  needles  should 
be  used,  and  a  strong  holder  without  a  lock  will  give  greater  leverage, 
with  less  fatigue  than  any  other.  Grasp  of  the  needle  and  forward 
pressure  are  made  simultaneously  and  are  equal  in  force.     The  for- 


1  2 

Fig.  23.— 1,  Small  needle  holder  with  catch  (Collin) ;  2,  Pozzi's  holder  for  flat  needles. 


ceps  used  by  A.  Martin  (Fig.  24, 1)  is  of  unusual  size,  but  I  can  testify 
from  personal  experience  that  it  is  not  too  large.  Collin  has  made 
for  me  a  needle-holder  of  this  description  for  large  ordinary  needles 
(Fig.  24,  2)  and  one  for  Hagedorn's  needles  (Fig.  24,  3).  The  latter 
seems  to  me  greatly  superior  to  the  spring-forceps  of  the  German  sur- 
geon. For  the  intestinal  sutures  which  may  be  required  during  a 
laparatomy,  round  sewing  needles  will  be  found  to  make  a  smaller 


44 


CLINICAL    AND    OPERATIVE   GYNAECOLOGY. 


incision  than  any  of  the  foregoing.  Fignre  25  shows  the  most  fre- 
quently used  intestinal  sutures;  those  of  Lembert,  Czerny,  and 
Gussenbaur. 

Suture  Materials. — Formerly  hemp,  silk,  and  linen  threads  were 
used  for  suturing;   the  laws  of  antisepsis  had  not  then  been  formu- 


Fir.  24.— 1,  Martin's  needle  holder;  2,  holder  for  large  ordinary  needles;  3,  Pozzi's  holder  for  large 
Hagedorn  needles.    (Each  14  size.) 


lated,  and  the  necessity  for  aseptic  suture  materials  was  unknown ; 
the  threads  in  use,  by  their  porous  qualities,  were  veritable  breeding 
places  for  germs,  and  suppuration  invariably  followed  their  use.  The 
introduction  of  wire  sutures  by  the  American  gynaecologist  Sims,  was 
a  step  in  advance  whose  importance  at  the  time  could  scarcely  be 
exaggerated.     Silver  wire  was  of  all  the  most  aseptic,  which  no  doubt 


METHODS    OF   SUTUKE   AND   HJSMOSTASIS.  45 

accounts  for  the  marvellous  results   obtained  and  the   enthusiasm 
aroused  by  its  use. 

Even  at  this  date  it  is  in  general  use,  in  France  especially,  and  it 
certainly  possesses  some  advantages.  On  the  other .  hand  it  breaks 
easily;  when  tied  around  a  somewhat  thick  mass  of  tissue  it  cuts  it 
more  than  other  threads ;  it  requires  more  time  for  its  application.  If 
it  is  cut  off  short,  the  ends  wound  the  vagina  and  the  perineum ;  if 
left  long,  they  may  be  pulled  upon.  For  these  reasons  I  have  almost 
abandoned  its  use,  replacing  it  with  catgut  or  antiseptic  silk.  Hegar * 
makes  use  of  wire  in  cavities  like  the  vagina,  where  silk  easily  becomes 
septic.  In  my  opinion,  however,  frequent  injections  of  bichloride  or 
insufflations  of  iodoform  would  suffice  to  prevent  sepsis. 


1  2  3 

Fig.  25. — Intestinal  Sutures.    1,  Czerny's  suture;  2,  Lembert's  suture;  3,  Gussenbauer's  suture. 

Silk- worm  gut  is  as  impermeable  and  non-absorbable  as  silver  wire; 
it  is  less  easily  broken,  but  less  flexible,  and  applicable  to  all  cases 
where  wire  is  used ;  it  is  given  the  pref erence  by  many  authorities,  as 
Bantock  and  Sanger.  I  find  that  the  knot  does  not  hold  as  well  as 
that  of  catgut  or  silk,  and  that  it  is  as  difficult  to  twist  as  wire,  so  that 
the  stitches  seem  to  me  somewhat  insecure.  Moreover  the  ends  be- 
come stiff  as  they  dry,  which  is  a  matter  of  some  importance  in  plastic 
operations  on  the  vulva  and  vagina.  Nevertheless  it  is  a  good  mate- 
rial for  sutures.  The  best  is  slightly  reddish  in  color;  it  should  be 
soaked  in  a  carbolic  or  bichloride  solution  for  about  a  quarter  of  an 
hour  before  using,  otherwise  it  will  be  inconveniently  stiff. 

The  best  silk  is  the  braided,  and  not  the  twisted  variety ;  it  comes 
in  very  fine  strands,  and  when  rendered  antiseptic  is  an  excellent 
suture  material.  It  may  even  be  used  for  buried  sutures ;  "Billroth 
uses  it  exclusively.  Experimentation  has  shown  that  not  only  is 
it  well  borne  by  the  tissues,  but  that  it  is  even  absorbed  by  them, 
yet  in  these  two  particulars  it  is  inferior  to  good  catgut.  Therefore 
in  cases  where  there  is  no  especial  resistance  to  be  overcome,  and 


46  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

where  the^  suture  need  not  remain  for  any  great  length  of  time,  I 
should  use  catgut,  but  in  suturing  the  intestines,  the  stomach  or  the 
bladder,  I  give  silk  the  preference.  It  is  also  desirable  to  insert  silk 
sutures  at  intervals  to  support  a  continuous  catgut  suture. 

Owing  to  the  porosity  of  silk,  it  possesses  one  serious  drawback ; 
that  of  secondary  infection.  Buried  silk  sutures  in  any  place  where 
suppuration  is  likely  to  occur  may  be  the  cause  of  fistulse,  which  will 
not  close  until  the  septic  piece  of  silk  be  eliminated.  In  such  cases, 
it  will  be  found  best  to  use  catgut  for  ligatures  and  silk-worm  gut  for 
the  sutures;  being  non-absorbent  they  are  less  liable  to  infection. 
This  applies  with  peculiar  force  to  operations  for  pyo-salpinx  and  pel- 
vic abscess,  where  the  sutures  come  in  contact  with  suppurating  mat- 
ter, and  in  sutures  of  the  abdominal  walls,  where  they  are  placed  near 
drainage  tubes  or  tampons.  Here  catgut,  silk-worm  gut,  or  silver  wire 
should  be  employed.  There  is  no  material  used  for  ligature  and 
suture  in  either  general  surgery  or  gynaecology,  to  be  compared  to 
catgut.  Its  property  of  disappearing  by  absorption  in  from  eight  to 
fifteen  days,  according  to  its  thickness  and  the  method  of  its  prepa  ra- 
tion, renders  it  invaluable  for  sutures  buried  in  the  abdominal  cavity, 
and  for  operations  on  the  cervix  and  vagina,  where  the  removal  of  the 
stitches  is  attended  by  both  difficulty  and  pain.  Catgut  prepared  in 
chromic  acid  is  the  only  kind  which  is  not  absorbed.  It  is  then  even 
more  durable  than  silk.  I  use  it  exclusively  in  my  operations,  occa- 
sionally reinforcing  it  by  a  supporting  suture  of  silk  or  of  silver  wire. 
Catgut  loosens  more  readily  than  silk,  and  should  be  tied  in  three 
knots  to  avoid  mishaps.  The  commercial  article  is  unsatisfactory ;  it 
should  always  be  prepared  by  one's  self  or  a  competent  assistant.  In 
spite  of  its  drawbacks,  however,  I  think  that  Kocher,  of  Berne,  carries 
his  objections  to  it  too  far,  and  consider  it  too  valuable  to  be  dis- 
carded.2 

Methods  of  Suture. — The  tendency  of  the  present  day  is  toward 
simplicity,  and  the  reduction  of  the  number  of  sutures  in  practical  use 
for  gynecological  operations  to  a  few  well-chosen  methods,  of  which 
the  following  are  the  chief: 

1.  Interrupted  suture. 

2  and  3.  Simple  continued  suture  and  continued  sutures  in 
layers  (etages). 

4.  Mixed  sutures. 

5.  Quilled  suture. 

1.  Interrupted  Suture. — Whatever  the  extent  of  the  wound,  its 


METHODS   OF   SUTURE   AND   ILEMOSTA8I8.  47 

surface  must  all  be  taken  in  by  the  suture,  otherwise  x>ocketing  and 
an  accumulation  of  11  aid  may  result  which  will  distend  the  wound, 
preventing  union,  and  may  increase  the  chances  of  sepsis.  To  meet 
this  requirement  Hegar,  following  Simon's  method,  directs  the  needle 
deeply  under  the  whole  surface  of  the  wound,  so  that  the  suture  is 
imbedded  in  tissues.  Occasionally  the  thread  may  cross  the  wound 
at  about  half  an  inch  or  an  inch  above  the  denuded  surface  (Fig.  26). 
The  needles  used  in  approximating  surfaces  (as  in  colpo-perineor- 
raphy,  etc.)  should  be  both  long  and  strong.  After  uniting  the  deeper 
tissues  by  these  concealed  sutures,  the  lips  of  the  wound  should  be 
drawn  together  by  superficial  stitches,  placed  near  the  margin.  These, 
while  applied  last,  are  tied  first;  the  deeper  stitches  are  tied  last. 
This  method  insures  a  more  exact  approximation.     The  deeper  the 


Fig.  26.— CorRSE  op  Interrupted  Sutures,    a,  a,  Deep  suture  including  whole  surface  of  wound;  b,  b, 
suture  including  a  part  only  of  the  denuded  surface;  c,  c,  superficial  suture  including  edjces  only  of  wound. 

wound,  the  farther  from  the  edge  should  be  the  point  of  entrance  and 
exit  of  the  needle  (Fig.  26).  Traction  exerted  upon  one  long  strand, 
certainly  puckers  the  edges  of  the  wound ;  to  correct  this  defect  the 
idea  w^as  conceived  of  using  buried  sutures  in  layers  of  different 
depths.  A  layer  of  interrupted  catgut  sutures  brings  together  the 
deepest  portion  of  the  wound,  successive  layers  approximating  the 
remainder  of  the  surface.  Werth,3  in  1879,  applied  this  method  to 
perineorrhaphy ;  Schroeder  and  his  school  at  once  adopted  it.  In  many 
cases  it  is  an  excellent  procedure,  but  it  possesses  the  disadvantage  of 
leaving  knots  of  the  catgut  in  the  depths  of  the  wound,  materially 
interfering  with  the  approximation  of  the  surfaces.  The  continuous 
suture  has  obviated  this  difficulty.  When,  at  the  instigation  of  a 
number'  of  surgeons,4-  this  suture,  so  long  in  disuse,  was  again  brought 
forward,  Brose3  lost  no  time  in  applying  it  to  the  plastic  operations 
of  gynaecology.     Schroeder  and  his  pupils  likewise  made  extensive 


48 


CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 


use  of  it.6  It  is  both  efficacious  and  rapid  in  its  application,  and  is 
particularly  useful  where  several  operations  have  to  be  done  at  one 
sitting;  as,  for  example,  amputation  of  the  cervix  with  anterior  col- 
porrhaphy,  colpo-perineorrhaphy,  and  Alexander's  oj>eration.  (Patient 
with  hypertrophied  cervix  and  genital  prolapse.) 

Simple  Continued  Suture. — This  can  be  advantageously  employed 
wherever  the  surfaces  to  be  approximated  are  neither  extensive  nor 


Fig.  27. — 1,  First  step  in  a  continued  suture.    I,  1,  Catgut.    2,  Final  steps  in  the  continued  suture. 


deep;  it  is  also  used  in  hsemostasis,  as  I  have  already  remarked.  The 
needle  is  introduced  at  one  extremity  of  the  wound,  and  the  terminal 
end  of  the  catgut  tied  in  three  knots,  leaving  a  short  free  end  which 
is  grasped  by  forceps  (in  the  cut  is  shown  Baumgartner's  forceps,  spe- 
cially constructed  to  facilitate  traction  upon  the  thread  in  deep  liga- 
tures). This  is  held  by  an  assistant,  and  serves  to  steady  the  suture 
(Figs.  27  and  28).  Introducing  the  needle  a  little  from  the  edge,  it 
is  carried  below  the  surface  of  the  wound  and  emerges  at  a  corre- 
sponding point  on  the  opposite  side;  the  thread  is  gently  pulled 
through,  and  an  assistant  holds  the  forceps  while  the  second  stitch  is 


METHODS    OF    SUTURE   AND    HJEMOSTASIS. 


49 


taken.  He  must  be  cautioned  not  to  let  it  go  suddenly  when  the 
second  stitch  is  drawn  through,  but  to  follow  the  motion  with  his 
hand  to  prevent  relaxation  of  the  first  stitch.  When  the  suture  is 
about  half  done,  it  is  well  to  make  light  traction  upon  the  opposite 
angle  of  the  wound  with  a  bullet  forceps,  in  order  to  have  the  edges 
even.  The  thread  may  be  tied  to  the  eye  of  the  needle  to  prevent 
slipping. 


Fig.  28.— 1,  Continuous  suture  in  layers  (one  at  the  angle,  two  in  the  centre  of  the  wound) ;  2,  continuous 
sutures  in  layers  (one  at  the  extremities,  three  in  the  centre  of  the  wound). 


3.  Continuous  Sutures  in  Layers. — These  are  used  where  one  row 
of  sutures  does  not  suffice  to  approximate  the  denuded  surfaces.  In 
this  case  the  needle,  instead  of  being  introduced  through  the  skin  out- 
side of  the  wound,  is  carried  into  the  raw  surface,  the  distance  from 
the  edge  depending  upon  the  extent  of  the  wound,  and  the  depth  to 
which  the  needle  can  be  carried.  When  the  deepest  surfaces  have 
been  drawn  together,  the  sutures  are  taken  through  the  skin,  and  the 
operation  is  terminated  by  a  superficial  spiral  suture  forward  and  then 
back  (Fig.  28).-  It  may  be  necessary  to  make  three  layers  of  stitches. 
They  should  not  be  taken  too  closely  together  nor  pulled  too  tightly. 

4 


50 


CLINICAL   A1STD   OPERATIVE   GYNAECOLOGY. 


We  may  fasten  the  suture  in  several  ways.  If  we  have  brought 
the  thread  by  a  second  layer  back  to  the  starting-point,  we  simply  tie 
it  three  times  to  the  projecting  end;  if  the  ends  of  the  thread  are  not 
together,  we  draw  the  last  stitch  oat  into  a  long  loop  and  tie  that  to 
the  end;  or  we  may  draw  the  end  of  the  thread  through  the  eye  of 
the  needle  in  such  a  way  as  to  leave  a  projecting  end  after  the  last 
stitch  is  taken — this  we  tie  to  the  double  loop  of  the  stitch. 

If  in  suturing  the  upper  part  of  the  wound,  the  thread  of  the 
deeper  suture  should  accidentally  be  cut,  or  should  it  break,  another 
stitch  should  immediately  be  taken  at  the  point  of  rupture  and  se- 
curely tied ;  the  suture  is  continued  with  this  second  thread.     Where- 


Fig.  29. — Suture  in  Layers.    Shows  method  of  fastening  the  thread,  in  the  middle  of  the  suture  by 

means  of  a  loop. 


ever  the  thread  is  liable  to  be  much  pulled  upon,  as,  for  instance,  ai 
the  point  where  the  suture  changes  its  direction,  I  strongly  recom- 
mend the  insertion  of  supporting  stitches  of  silk  or  silver  wire,  to  take 
off  the  strain  from  the  catgut  (Fig.  30). 

In  a  perineorrhaphy  I  place  one  at  each  extremity  of  the  perineum ; 
the  anterior  one  encircling  the  terminal  point  of  the  reconstructed 
recto-vaginal  partition,  the  posterior  uniting  the  extremities  of  the 
anal  sphincter.  In  a'  colpo-perineorrhaphy,  I  put  in  one  only  at  the 
fourchette. 

4.  Mixed  Sutures. — It  is  often  advisable  to  combine  the  inter- 
rupted and  continued  sutures.  To  illustrate  this  point,  I  Avill  describe 
my  mode  of  procedure  in  closing  the  abdominal  opening  after  a  lap- 
aratomy. 

As  soon  as  the  peritoneum  has  been  cleansed,  a  protective  gauze 
sponge  is  spread  like  an  omentum  over  the  intestines,  and  an  assistant 
draws  the  edges  of  the  wound  together  and  holds  them  in  place.     With 


METHODS   OF   SUTURE   AND   II.EMOSTASIS. 


51 


a  curved  needle  and  catgut  of  moderate  thickness,  a  stitch  is  taken  in 
the  peritoneum  at  the  lower  part  of  the  wound,  the  end  of  the  catgut 
being  held  with  a  forceps  to  exert  a  certain  amount  of  traction ;  with- 
out cutting  the  thread,  the  operator  rapidly  sutures  the  peritoneum 
with  long,  basting  stitches  (Fig.  31);  when  the  upper  part  of  the  wound 
is  reached,  the  gauze  sponge  is  withdrawn,  and  the  operator  now  re- 
turns to  the  starting-point  by  a  somewhat  closer  row  of  stitches  on 
the  aponeuroses,  closing  in  any  muscle  sheath  which  may  have  been 
opened  (Fig.  32).     The  forceps  are  now  removed  and  the  two  ends  of 


Fig.  30.— Continuous  Suture  is  Layers  in  Operation  for  Ruptured  Perineum.  1,  2,  3,  Course  taken 
Iny  the  thread;  a,  b,  simple  continued  suture;  c,  interrupted  supporting  suture;  d,  starting-point  of  the 
-continued  suture  in  layers. 

the  catgut  united.  There  now  remains  only  the  joining  of  the  integ- 
ument, and  the  subcutaneous  tissue,  which  often,  however,  forms  a 
very  thick  layer.  With  a  large  curved  needle,  and  silk  of  a  strength 
proportioned  to  the  thickness  of  the  parts  to  be  traversed,  separate 
stitches  are  placed  at  intervals  of  about  a  half-inch.  These  sutures 
are  introduced  at  about  the  same  distance  from  the  edge  of  the 
wound,  penetrate  through  the  adipose  tissue  until  the  aponeurosis  is 
reached,  and  return  in  a  similar  manner  through  the  second  lip  of  the 
wound.  Both  ends  of  each  suture  are  held  by  forceps,  the  wound  is 
now  washed  with  a  strong  carbolic  solution,  the  edges  are  approxi- 
mated, and  with  a  small  needle  and  fine  catgut,  or  silk-worm  gut,  one  or 


52 


CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 


two  superficial  interrupted  sutures  are  placed  in  each  interval  be- 
tAveen  the  deep  sutures.  They  must  be  quite  close  to  the  edges  and 
bring  them  into  exact  juxtaposition.  (I  often  replace  these  by  a  fine 
continued  catgut  suture.)  !Not  until  these  are  inserted  and  tied,  are 
the  forceps  taken  from  the  ends  of  the  deep  sutures  and  these  firmly 
fastened  (Fig.  33). 

If  the  abdominal  walls  be  rigid,  as  in  nulliparae,  or  tense  from 


Fig.  31.— Suture  op  Abdominal  Walls  after 
Hysterectomy.  First  stage  of  the  continuous 
suture  (peritoneum). 


Fig.  32. — Second  Stage  of  Continuous  Su- 
ture (Musculo-aponeurotic  Layer). 


meteorism  or  tumors,  all  the  deep  interrupted  sutures  should  be  made 
with  silk  instead  of  catgut. 

5.  Quilled  Sutures.— Small  rolls  of  iodoform  gaiize  are  now  sub- 
stituted for  the  quills  and  lead  plates  in  former  use.  Lister's  button 
suture,  with  the  heavy  silver  wire  and  piece  of  lead,  has  also  been 
superseded  by  better  processes.  It  is  no  longer  used  in  perineorrha- 
phies, but  there  are  some  exceptional  cases  where  it  may  be  employed. 


METHODS    OF   SUTURE   AND   iLEMOSTASIS. 


53 


For  instance,7  where  a  large  abdominal  tumor  adheres  anteriorly  to 
the  parietal  peritoneum,  its  removal  will  leave  an  extensive  raw  sur- 
face, caused  by  the  stripping  of  the  peritoneum  from  the  internal 
abdominal  wall.  The  liability  to  septicaemia  is  increased  by  the  pres- 
ence of  this  large  and  moist  surface.  It  will  then  be  found  useful,  be- 
fore closing  the  abdomen,  to  carry  a  long,  deep  suture  from  one  side 
to  the  other,  supporting  it  at  each  end  with  a  roll  of  iodoform  gauze. 


Tig.  33.— Suture  of  Abdominal  Walls  after  Hysterectomy.    Interrupted  suture  of  the  integuments 

and  subcutaneous  areolar  tissues. 


This  will  fold  the  abdominal  walls  above  and  parallel  to  Poupart's 
ligament;  will  exercise  a  beneficial  pressure  upon  the  raw  surfaces, 
prevent  hemorrhages  and  serous  exudation,  and  thus  eliminate  one 
source  of  infection.  These  sutures  can  be  withdrawn  in  from  five  to 
six  days. 

Hcemoslasis. — We  have  compression  for  capillary  hemorrhages; 
torsion  for  small  arteries,  suture  for  the  surface  of  wounds.  But  the 
two  methods  to  which  I  call  especial  attention  are  ligation  and  forci- 


54 


CLINICAL   AND    OPEEATIVE   GYNAECOLOGY. 


pressure.  I  shall  not  touch  upon  ligation  of  the  vessel  alone,  as  it  has 
no  especial  bearing  npon  the  subject  in  hand,  but  pass  on  to  ligature 
in  mass,  which  is  of  superlative  interest  in  gynaecology,  and  by 
means  of  which  we  are  able  to  control  the  often  formidable  hemor- 
rhages of  the  pedicles  of  abdominal  tumors.  Wire,  silk,  catgut,  elas- 
tic cords,  and  tubes  have  all  been  used  in  its  application.     We  shall 


FIG.  34.— 1,  An  improperly  tied  surgeon's  knot;  2,  properly  tied  surgeon's  knot;  3,  transfixion  of  the- 
pedicle  with  a  needle  and  loop  of  silk;  4,  crossing  of  ends  of  silk  after  transfixion  of  pedicle;  5,  Bantock's 
knot  for  ligation  of  small  pedicles;  6,  Lawson  Tait's  knot  (Staffordshire  knot)  for  ligation  of  small  pedicles- 
(the  loop  is  to  be  thrown  over  the  tumor);  7,  continuous  ligature  for  a  large  pedicle;  crossing  of  threads; 
8,  continuous  ligature  for  large  tumor;  threads  tied  (side  view). 


take  up  the  matter  more  in  detail  when  we  study  the  subjects  of 
ovariotomy  and  hysterectomy. 

Silk  is  the  most  widely  used  agent  for  ligation  in  mass,  as  it  offers 
the  greatest  amount  of  resistance  in  the  smallest  bulk.  Braided  and 
not  twisted  silk  is  always  to  be  used.  When,  however,  the  ligatures 
are  to  be  buried  in  the  abdomen  (as  in  Schroeder's  hysterectomies,, 
and  Martin's  intra-peritoneal  enucleations)  it  will  be  found  disadvan- 
tageous to  use  a  material  which  is  non-absorbable  for  a  great  length. 


METHODS    OF   SUTURE   AND    IIJEMOSTASIS. 


55 


of  time,  and  yet  so  absorptive  as  to  increase  the  liabilities  of  secondary 
infection.  Since  catgnt  prepared  in  oleum  juniperi  does  not  possess 
these  drawbacks,  many  gynecologists  (Veit,  Martin,  etc.)  do  not  hesi- 
tate to  substitute  its  use  for  that  of  silk  in  buried  ligatures,  notwith- 
standing the  fact  that  it  is  more  difficult  to  tie  it  tightly  than  the  silk. 

I  will  briefly  mention  the  different  methods  of  ligature  in  mass. 

If  the  part  to  be  embraced  is  relatively  thin,  one  loop  of  thread  is 


Fig.  35. — Continuous  Ligature.    Method  of  intro-  Fig.  36. — 1,  2,  Continuous  Ligature.    Method  of 

ducing  threaded  needle   twice   through  the  same       introducing  threads  of  the  second  loop.    The  first 
opening  (membranous  pedicle).  .  loop  transfixes  the  pedicle  and  is  then  cut,  which 

leaves  a  protruding  end;  this  is  threaded  into  a 
blunt  needle  in  company  with  a  new  thread,  and 
the  two  are  again  carried  through  the  pedicle. 

passed  around  it  and  securely  fastened  with  a  surgeon's  knot  (Fig. 
34,  1,  2). 

If  the  pedicle  is  thick  and  yet  requires  only  two  loops,  it  must  be 
transfixed  in  the  centre  by  a  needle  threaded  double  (Fig.  34,  3) ;  the 
loop  is  cut,  which  leaves  two  ends  on  each  side  of  the  pedicle ;  these 
are  crossed  and  tied  on  either  side  (Fig.  34,  4)  or,  better  yet,  to  avoid 
having  two  knots  (knots  being  less  well  tolerated  by  the  tissues  than 
the  rest  of  the  thread)  we  may  use  Bantock's  knot  (Fig.  34,  5)  or  Law- 
son  Tait's  Staffordshire  knot  (Fig.  34,  6).     In  a  laminated  pedicle,  such 


56 


CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 


as  we  find  in  certain  ovarian  pedicles,  membranous  adhesions,  or 
broad  ligaments,  we  pass  a  series  of  ligatures,  so  linked  together  that 
when  they  are  tightened  no  laceration  of  the  tissues  results  (Fig.  34, 
7,  8).  Figures  35,  36,  37,  38,  show  with  sufficient  clearness  the 
methods  generally  used  in  applying  these  ligatures,  as  well  as  the 


Fig.  37.— Continuous  Ligature  (Wallich).  1,  Deschamp's  blunt  needle  transfixing  the  pedicle;  one 
thread  of  the  loop  is  to  be  seized  at  A  and  kept  outside  the  pedicle,  the  other  long  end,  B,  is  held  coiled  in 
the  Land  of  the  operator;  2,  the  loop  is  grasped  by  the  forceps  and  held  while  the  needle  is  withdrawn;  it 
slides  down  the  thread,  2?,  and  then  following  the  direction  indicated  by  the  arrows,  pierces  the  pedicle 
again,  leaving  a  second  loop  in  place. 


method  which  Wallich 8  proposes  to  employ  in  their  stead.  This  is 
very  similar  to  that  of  J.  W.  Long,9  except  that  he  uses  one  fixed 
needle  (a  double-eyed  needle  seems  to  me  useless)  while  Long  has 
a  series  of  ordinary-pointed  needles,  very  imperfect  for  the  purpose 
(Fig.  39). 


METHODS   OF   SUTUEE   AND   H-EMOSTASIS. 


57 


I  will  merely  allude  to  the  kangaroo  ligatures  proposed  for  use  by 
American 10  operators,  and  to  the  reindeer  ligatures  (threads  of  osti- 
akes)  recommended  in  Russia.11  They  doubtless  possess  a  remarkable 
power  of  resistance,  and  when  deprived  of  their  fatty  constituents  by 
ether,  and  submitted  to  a  process  similar  to  that  used  in  the  prepara- 


2  ft 

Fig.  38.— Steps  in  the  Application  of  Wallich's  Continuous  Ligature.    1.  The  threads  in  place, 
the  loops  are  to  be  cut  at  a,  crossed  and  tied  ;  2.  Threads  crossed,  tied,  and  ready  to  be  tightened. 

tion  of  catgut,  would  be  a  better  material  for  ligature  in  mass.  But 
the  difficulty  of  obtaining  them  renders  their  general  use  in  this  coun- 
try impossible.  Ligature  in  mass  upon  the  surface  of  the  body  causes 
death  of  the  strangulated  tissues.  When  buried  in  the  abdomen,  with 
antiseptic  precautions,  the  constricted  portions  do  not  mortify,  their 
vitality  being  preserved  by  vascular  adhesions  and  by  blood-vessels 
which  pass  like  a  bridge  over  the  groove  of  the  ligature.     After  a 


58 


CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 


while  the  stump  shrivels  and  is  absorbed.     This  has  been  well  shown 
by  experiments  on  animals. 

Hegar  has  witnessed  the  perfect  absorption  in  a  few  weeks,  by  the 
peritoneum  of  a  dog,  of  freshly-extirpated  bits  of  muscle;  and  Czerny 
has  seen  the  same  thing  with  portions  of  cancer,  Ziegler  with  frag- 
ments of  bone,  and  Tillmans  with  pieces  of  liver,  kidney,  and  lung.12- 


9.10.  H 


Fig.  39.— Chain  Suture  with  a  Series  of  Needles,  Long's  Process  (op  Asheville).  1.  Series  of 
needles  threaded  on  one  thread  ;  2.  Insertion  of  first  loop.  Second  needle  transfixes  the  pedicle  3.  All  the 
loops  in  place. 

Thomson  has  made  a  series  of  interesting  experiments  with  the 
suture  materials  most  in  use  for  laparatomies.  Carbolized  catgut  is 
absorbed  in  ten  days;  chromic  acid  catgut  lasts  for  several  months,  as 
Sanger  and  Doderlein  ascertained  upon  patients  who  survived  Cesa- 
rean section.  Silk- worm  gut  was  intact  at  the  end  of  two  months.19 
Silk  is  somewhat  disorganized  at  the  end  of  fifty  days.  The  silk 
threads  are  at  first  infiltrated  with  a  new  cell  growth,  become  en- 
cysted, and  finally  disappear,  but  this  is  a  process  which  it  takes 
several  months  to  accomplish,  and  before  that  time  they  may  play 


METHODS    OF   SUTURE   AXD    HjEMOSTASIS. 


59 


the  part  of  foreign  bodies.  The  only  explanation  of  this  infection  is 
the  passage  of  germs  through  the  intestines  or  the  Fallopian  tubes ; 
unless,  indeed,  we  admit  the  existence  of  a  species   of  latent  mi- 


Fig.  40. — Hegar's  Forceps  Temporarily  Holding  an  Elastic  Ligature  in  Place,  while  a  Perma- 
nent Ligature  is  being  Adjusted. 

crobism,  called  into  activity  by  a  vicious  local  or  general  condition.1 
To  avoid  infection  when  the  cut  surface  of  the  pedicle  may  be  septic- 
(salpingitis,  etc.)  it  is  best  to  use  catgut,  or  to  use  both  cauterization 


Fig.  41. — Elastic  Ligature  tied  with  Silk  Thread  (Hegar). 

and  ligature  in  mass.     The  aserjtic  slough  produced  by  the  hot  iron 
is  rapidly  absorbed. 

Kaltenbach  u  found  in  a  subject  who  had  died  of  tetanus  eight  days 
after  the  operation,  that  the  cauterized  surface  was  smooth,  charred. 


w 


CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 


and  showed  no  trace  of  inflammation.  Heppner,15  after  an  interval  of 
two  years,  found  the  merest  trace  of  animal  charcoal  in  the  neighbor- 
hood of  the  pedicle. 

Of  elastic  ligature,  buried  or  on  a  free  surface,  I  shall  here  mention 
only  a  few  general  points,  reserving  technical  details  for  the  chapter 
on  hysterectomy.  It  has,  however,  been  used  in  the  ligation  of  other 
than  uterine  pedicles.  Hegar  uses  it  in  profusely  bleeding  ovariot- 
omies. To  keep  the  elastic  cord  in  place,  Olshausen  ties  it  twice,  and 
with  a  few  additional  silk  stitches  fastens  it  to  the  pedicle.  Thiersch 
-draws  the  ends  through  a  leaden  ring,  which  he  then  compresses. 
Hegar  ties  two  silken  ligatures  around  the  elastic,  at  a  little  distance 
from  each  other  (Figs.  40,  41.  42).     Since  I  first  introduced  an  instru- 


Fig.  42.— Hegar's  Forceps  for  the  Temporary  Fixation  of  an  Elastic  Ligature. 


ment  for  placing  ligatures  many  modifications  have  been  proposed, 
not  only  to  facilitate  the  application  of  the  cord,  but  also  to  keep  it  in 
place.  I  consider  this  last  precaution  superfluous,  as  two  threads  of 
silk  fully  accomplish  the  purpose  without  the  intervention  of  any 
instrument.  My  ligator  (Figs.  43,  44,  45,)  which  I  introduced  in  the 
Surgical  Society  in  1883,  and  with  improvements  at  the  medical 
congress  in  1885,  is  intended  solely  to  facilitate  the  placing  of  an  elas- 
tic ligature  in  a  narrow  space,  as  the  pelvis  or  vagina.  It  is  easily 
managed,  and  can  be  taken  apart  to  insure  perfect  cleanliness.  Col- 
lin's device  (Fig.  46,  1)  is  a  simplification  of  my  instrument,  and  lends 
itself  less  readily  to  the  tightening  of  the  elastic  loop  after  this  is  in 
2uace.  The  ligators  of  Terrillon  and  Segond  16  (Fig.  45,  1,  2)  are  excel- 
lent for  holding  the  ligature,  which,  indeed,  is  all  they  aim  to  do,  but 
they  are  of  little  use  in  facilitating  the  introduction  of  the  ligature, 
w^hich,  it  seems  to  me,  should  be  the  chief  function  of  the  instrument. 
For  temporary  ligatures  they  are  not  much  of  an  improvement  on 


METHODS   OF   SUTURE   AXD   ELEMOSTASIS. 


61 


Hegar's  forceps  (Fig.  42)  or  Walcher's  clamp 1T  (Fig.  46, 2),  and  for  per- 
manent ligatures  I  have  already  said  that  two  silk  threads  are  better. 
For cipres sure. — The  process  of  obtaining  hremostasis  by  the  tem- 
porary or  permanent  application  of  forceps  is  of  ancient  date.  For  a 
long  time  Charriere,  the  well-known  manufacturer  of  instruments,  at- 
tempted to  induce  surgeons  to  adopt  forcipressure.     In  his  catalogue, 


1  3  4  5 

Fig.  43.— 1,  2,  Segond's  elastic  ligator;  3,  4,  5,  Pozzi's  ligator  taken  apart. 

published  the  loth  of  April,  1851  (printed  by  Thunot,  Rue  Racine), 
p.  11,  Fig.  53,  he  shows  forceps  almost  identical  with  the  Koeberle- 
Pean  forcipressure  instrument.  It  is  thus  described  in  the  text: 
"  Ring-forceps,  with  crossed  and  uncrossed  handles,  Charriere's  model, 
designed  to  seize  insects  and  reptiles  in  narrow  spaces.  These  same 
forceps  can  be  made  with  our  ratchet  catch  which  keeps  them  firmly 
closed  when  desired."  In  1859,  in  another  edition  of  his  catalogue 
(Plon,  printer),  p.  6,  Charriere  has  a  paragraph  upon  the  methods  of 


62 


CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 


fixation  by,  1st,  the  two  handles  of  the  polypus  and  oesophageal  ring- 
forceps,  and  hooked  forceps.     2.  Artery  forceps.     He  describes  the 


?:,../ 


Fig.  44.— Application  op  Pozzfs  Elastic  Ligatukk.  1,  First  Step.  The  lower  part  of  the  elastic  cord 
is  held  in  the  furrow  while  the  cord  passing  under  the  open  clamp  is  engaged  by  pressure  in  the  head  of 
the  instrument ;  2,  second  step.  The  cord  has  been  twice  passed  around  the  pedicle,  then  again  engaged  by- 
pressure  in  the  head  of  the  instrument. 

insertion  of  a  screw  on  the  one  blade  into  a  hole  on  the  second  blade, 
and  adds :  "  This  system,  which  transforms  a  ring  or  dressing  forceps 
(so  called  awhile  ago)  into  a  continuous  pressure  forceps,  will  permit 


METHODS    OF   SUTURE   AND    HiEMOSTASIS.  C3 

the  carrying  of  needles  into  deep  cavities,  .  .  .  and  the  pressure  upon 
vessels  to  prevent  hemorrhages  during  operation."  True,  Charriere 
had  in  mind  only  a  temporary  hsemostasis,  for  he  adds:  "The  conical 


Fig.  45. — Application  op  Pozzi's  Elastic  Ligature.  1,  Third  Step.  The  elastic  cord  drawn  under  the 
•clamp  is  held  in  place  by  it;  2,  fourth  step,  the  lower  part  of  the  cord  is  disengaged  from  the  furrow;  the 
instrument  is  taken  apart  by  unscrewing  the  lower  part  of  the  shank  on  a  level  with  the  upper  part  of  the 
groove.  Only  the  head  of  the  instrument  remains  temporarily  in  place.  (At  the  left  is  a  representation  of 
the  chain  suture  of  the  broad  ligament.) 


shajje  of  the  jaws  will  enable  one  to  apply  the  ligatures  deeply  on  the 
vessels."  Nevertheless,  he  realized  the  immense  value  of  these  forceps 
in  temporary  hsemostasis,  arid  dwells  upon  it  again  in  Menier's  "  Com- 
mercial Catalogue,"  5th  edition,  I860  (Plon,  printer).      On  page  276, 


64  CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 

Fig.  18,  he  shows  his  ring  and  continuous  pressure  forceps,  with  this 
remark  :  "  1.  This  instrument  is  of  use  as  an  ordinary  dressing 
forceps.  2.  The  elasticity  of  its  blades  permits  the  secure  seizure 
of  arteries  during  hemorrhage,  etc." 

I  have  thought  it  advisable  to  quote  from  these  documents  which 
are  unknown  to  the  majority  of  persons  who  have  discussed  the  ques- 
tion of  priority  in  this  matter.  It  certainly  proves  that  the  instrument 
which  was  destined  a  few  years  later  to  play  so  large  a  part  in  sur- 
gery, had  been  manufactured  by  Charriere  in  1851  for  another  pur- 
pose, and  in  1859  pointed  out  by  him  as  applicable  to  forcipressure. 

This  method  was,  however,  only  occasionally  used,  until  Koeberle 
and  Pean  adopted  it  to  save  time  in  major  abdominal  operations.  The 
question  as  to  which  of  these  two  preceded  the  other  in  its  use,  has 
given  rise  to  a  discussion  of  some  acerbity,  from  the  consideration  of 
which,  however,  it  is  difficult  to  reach  any  conclusion.  Koeberle 1S 
had  a  Strasburg  instrument  maker,  Elser,  manufacture  for  his  use 
some  forceps  very  like  Charriere's  dressing  forceps,  with  a  catch  to 
allow  of  graduated  pressure  of  the  tissues.  He  has  made  constant 
use  of  it  for  rapid  f orcipressure,  and  very  rarely  resorts  to  ligature ; 
this  is  evidenced  by  a  description  published  by  Revillout 19  of  the 
operative  procedures  of  the  Strasburg  surgeon,  and  by  one  published 
by  Koeberle  himself  shortly  after.20  He  speedily  applied  it  to  all 
operations.  Pean 21  in  the  beginning  used,  as  Koeberle  did  also,  the 
larger  serres-fines  of  Sedillot,  known  as  serres-fortes,22  but  in  1868  had 
Gueride  manufacture  for  him  some  forceps  for  forcipressure.  They 
were  of  various  kinds,  convenient  to  use,  and  may  be  seen  in  the  cata- 
logue of  that  instrument  maker.  The  sharpest  point  in  the  discussion, 
and  the  one  upon  which  it  is  most  difficult  to  form  a  just  opinion,  is 
this:  Did  Pean,  as  Koeberle  asserts,  adopt,  with  or  without  alteration, 
the  process  first  described  by  Revillout  ?  or  did  Pean,  as  he  himself 
declares,  from  the  same  operative  needs,  devise  the  same  procedure  as 
his  colleague  of  Strasburg  ?  This  would  be  a  very  natural  occurrence 
surely,  but  however  that  may  be,  Pean,  the  original  or  contemporary 
inventor  of  forcipressure,  has,  through  his  hospital  positions  and  large 
private  practice  in  Paris,  done  more  than  any  other  one  man  toward 
its  general  adoption. 

Verneuil,23  who  in  his  remarkable  paper  has  given  the  history  of 
the  application  of  forcipressure  to  hsemostasis,  also  helped  to  popu- 
larize and  regulate  its  use.  It  is  at  the  present  day  used  in  general 
surgery  as  well  as  in  gynaecology.24 


METHODS    OF    SUTURE    AND    H.EMOSTASIS. 


65 


The  popularizing  of  this  valuable  method  of  lnemostasis  is  due  to 
Koebeiie  in  the  lirst  place,  to  Pean,  and  finally  to  Verneuil. 

In  England,  Spencer  Wells  has  become  an  enthusiastic  apostle  of 
the  process,  and  its  use  is  now  general.25 

The  use  of  forcipressure  during  an  operation  is  of  great  value,  not 
only  for  the  immediate  arrest  of  bleeding,  but  because  the  temporary 


1  2 

Fig.  46. — 1,  Collin's  elastic  ligature-carrier;  2,  Walcher's  clamp  for  fixing  the  elastic  ligature. 

haBmostasis  effected  by  it,  nearly  always  becomes  permanent.  One 
may  by  its  means  perform  a  laparatomy  without  once  being  inter- 
rupted to  tie  an  artery. 

In  plastic  operations  the  use  of  this  method  must  not  be  carried  to 
excess,  for  the  pinching  to  which  some  portions  of  tissue  are  sub- 
jected by  the  forceps  is  an  obstacle  to  immediate  nnion. 


66 


CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 


Forcipressure,  as  well  as  ligature,  may  be  divided  into  that  which 
compresses  the  vessels  alone,  and  that  which  includes  in  its  compres- 
sion a  large  amount  of  tissue.  This  temporary  constriction  is  a  great 
adjuvant  to  permanent  hsemostasis.  It  is  desirable  to^have  on  hand 
forceps  of  various  kinds,  from  Billroth's  enormous  instrument,  suita- 
ble for  the  compression  of  fleshy  pedicles,  to  the  many  styles  invented 
or  modified  by  Koeberle,  Pean,  Terrier,  Spencer  Wells,  Tait,  Thornton, 
etc.     In  the  majority  of  cases,  forcipressure  is  resorted  to  as  a  tempo - 


Fig.  47.— Koeberle's  Hemostatic  Forgeps  with  Ratchet  Catch  Allowing  Graduated  Pressure  for 
Forcible  Compression;  a,  various  forms  of  jaws  for  pressure  forceps  (Pean);  6,  Lawson  Tait's  pressure  for 
ceps;  c,  Pean's  hemostatic  forceps  with  Collin's  joint. 


rary  measure ;  nevertheless,  in  cases  of  necessity,  it  has  been  utilized  for 
the  permanent  arrest  of  hemorrhage.  Pean  leaves  the  forceps  in  the 
peritoneal  cavity  after  abdominal  hysterectomy,  gathering  the  handles 
into  a  bundle  at  the  lower  extremity  of  the  wound;  this  process  is, 
however,  inferior  to  the  use  of  buried  elastic  ligatures. 

Forcipressure  has  been  used  by  many  surgeons  as  a  matter  of  ne- 
cessity in  vaginal  hysterectomy  (Pean,  Buffet,  J.  Boeckel,  Ch.  Jen- 
nings), but  it  remained  for  Spencer  Wells 26  and  Jennings  27  to  suggest 
its  use  as  a  matter  of  choice,  and  for  Bichelot  to  systematically  adopt 


METHODS   OF   SUTURE   AND   IIJEMOSTASIS. 


67 


it  as  such,  even  where  ligature  would  be  easier  and,  seemingly,  pre- 
ferable. Many  surgeons  now  do  the  same.  I  shall  return  to  this  sub- 
ject in  the  chapter  upon  uterine  cancer.^8  I  would  only  observe  in 
this  connection  that  hsemostasis  by  permanent  forcipressure,  when  in 
mass,  is  always  followed  by  the  death  of  a  much  greater  amount  of 


Fig.  48.— 1,  Billroth's  forceps  for  the  compression  of  fleshy  pedicles  (hysterectomy).    Medium  size,  one- 
fifth  actual  size;  2,  Spencer  Wells1  forceps  for  forcipressure  in  mass  of  pedicles  (ovariotomies). 


tissue  than  when  applied  to  isolated  ligature.     From  the  antiseptic 
point  of  view,  it  is  inferior  to  ligature. 

Drainage. — This  is  not  the  place  to  discuss  the  indications  for 
drainage,  whether  of  reunited  superficial  wounds  or  of  the  peritoneal 
cavity.  I  would  simply  establish  a  few  general  principles  and  point 
out  the  practical  methods  for  their  application. 


68 


CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 


Drainage  of  Wounds. — In  a  suture  in  layers  (etages)  of  the  ab- 
dominal cavity  after  laparatomy,  it  is  usually  not  necessary  to  place  a 
drainage  tube  between  each  series  of  stitches.  Yet  it  is  well  to  do  so 
if  the  surface  of  the  cut  has  been  exposed  to  infection,  for  instance, 
from  pus;  for  in  this  case,  notwithstanding  the  most  energetic  aseptic 


Fig.  49. — 1,  Thornton's  instrument  for  f orcipressure  in  mass  (ovariotomy) ;  2,  The  Pean-Terrier-Collin 
forceps  for  forcipressure  in  mass  (adhesions). 

washings,  a  serous  or  sero-purulent  exudation  may  supervene  and 
unless  it  is  promptly  carried  off  by  prophylactic  drainage,  may  inter- 
fere with  primary  union.  Under  these  circumstances  it  is  advisable 
to  place  a  small  drainage  tube  between  the  aponeurotic  and  cutaneous 
sutures;  this  tube  should  be  divided  into  three  segments,  and  a 
safety-pin  transfixing  the  outer  end  will  prevent  its  being  lost  in  the 
wound.     In  the  hospital  at  Pesth,  I  have  seen  used  in  place  of  the* 


METHODS    OF    SUTURE   AND    H.EMOSTASIS. 


69 


pin,  a  small  flat  piece  of  hard-rubber  sewed  to  the  end  of  the  tube 
with  two  lateral  stitches. 

The  best  drainage  tubes  are  of  thick  rubber,  uniting  elasticity 
which  keeps  them  open,  to  a  flexibility  which  permits  of  bending 
them  as  required. 

It  is  not  necessary  to  use  glass  or  hard-rubber  tubes  if  the  soft 
ones  at  hand  are  of  sufficient  thickness  and  good  quality. 

Drainage  of  the  Peritoneal  Cavity. — From  the  earliest  days  of 
laparatomy,  this  has  been  done  to  prevent  the  accumulation  of  liquids 
(blood,  ascitic  fluid,  more  or  less  septic  serum,  etc.).  Peaslee,  in  1855, 
first  pointed  out  the  necessity  for  it.  He  used  an  elastic  catheter  which 
penetrated  into  the  pouch  of  Douglas  and  emerged  through  the 
vagina.     Koeberle,  in  1867,  drained  through  the  abdominal  wound  by 


TTig.  50.— Instrument  fob  Fobcipbessore  in  Mass,  Curved  Lateballt  for  Vaginal  Hysterectomy 

(Pean  and  Richelot). 

means  of  a  glass  tube  terminating  in  a  bulb,  and  perforated  at  intervals 
in  its  entire  length  with  small  openings.  The  two  directions  to  be  taken 
in  peritoneal  drainage  were  from  that  time  determined.  But  the  de- 
batable ground,  then  and  now,  is  the  indication  for  drainage.  Sims, 
in  1872,  recommended  systematic  drainage  after  every  ovariotomy. 
This  exaggerated  view  at  least  showed  the  harmlessness  of  drainage 
when  attended  with  proper  precautions.  It  is  well  to  bear  in  mind 
that,  at  the  end  of  a  few  hours,  the  tube  is  surrounded  and,  in  a  mea- 
sure, isolated  by  a  newly  formed  pseudo-membrane.  Only  a  persistent 
oozing  in  the  abdomen  will  cause  the  formation  of  a  cavity  at  the 
end  of  the  tube  in  which  fluids  accumulate. 

The  problem  has  been  further  simplified  by  the  recognition  of  the 
great  absorptive  powers  of  the  peritoneum  when  this  physiological 
function  is  not  interfered  with  by  extensive  or  ragged  wounds,  or  by 
long  exposure  to  the  air  and  paralysis  of  the  intestines.  Consequently 
in  a  laparatomy  uncomplicated  by  the  above  conditions,  a  large 
amount  of  blood  or  serous  fluid  may  be  rapidly  absorbed  without  in- 
jury to  the  patient. 


70 


CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 


Chenieux 29  asserts  that  this  absorption  is  more  beneficial  than 
evacuation,  and  we  would  scarcely  wish  to  contradict  him.  The  diffi- 
culty consists  in  knowing  when  it  will  occur;  if  it  does  not  occur  at 
all,  septicemia  is  more  likely  to  follow.  I  have  said  in  a  preceding 
chapter  that  washing  the  peritoneum  temporarily  interferes  with  its 
absorptive  powers. 

(Wegener, 30  basing  his  conclusions  upon  experiments  with  dogs 


Fig.  51.— Instruments  of  Several  Sizes  for  Forcipressure  in  Mass  (Adhesions)  with  Collin's  Joint.. 

Natural  size. 

and  rabbits,  estimates  the  absorptive  powers  of  the  peritoneum  in  man 
at  two  and  a  half  quarts  an  hour;  toxic  injections  have  as  rapid  action 
1  as  if  introduced  directly  into  the  blood-vessels.) 

The  "  toilet "  of  the  peritoneum  having  been  properly  accomplished, 
after  a  laparatomy,  by  means  of  gauze  sponges  introduced  by  the 
finger  or  long  forceps  into  all  dependent  portions,  there  is  nothing  to 
fear  from  what  is  left  in  the  abdomen,  but  purely  from  what  may 
come  later  and  remain  there.     Each  and  every  surgeon  must  judge 


METHODS   OF   SUTURE   A^D   ELEMOSTASIS.  71 

for  himself  what  constitute  indications  for  drainage,  it  being  mani- 
festly impossible  to  lay  down  strict  laws;  yet  we  may  formulate  the 
principal  indications. 

1.  Abundant  parenchymatous  oozing  of  blood  or  serum  after  clo- 
sure of  the  abdominal  walls,  the  absorbing  power  of  the  peritoneum 
being  impaired  by  special  anatomical  or  clinical  conditions.  Drainage, 
in  this  case,  as  Tait  observes,  serves  not  only  to  carry  off  the  huid,  but 
possesses  haemostatic  action  as  well. 

2.  The  existence  in  the  peritoneal  cavity  of  a  septic  body  (shred 
of  a  cyst  wall,  suppurating  surface)  which  would  occasion  the  forma- 
tion of  fluid  whose  absorption  would  be  harmful ;  lesions  of  the  peri- 
toneum. 

3.  Large  tear  of  the  peritoneum  acting  in  two  ways,  (a)  as  a  source 
of  persistent  oozing,  (5)  as  an  obstacle  to  normal  absorption. 

4.  Long  duration  of  the  operation  and  manipulation  compromising 
the  tonicity  of  the  intestinal  walls  and  the  vitality  of  their  serous 
covering. 

Drainage  through  the  Vagina. — The  cul-de-sac  of  Douglas  being 
the  most  dependent  portion  of  the  pelvic  cavity,  it  seems  reasonable 
to  utilize  it  for  the  purpose  of  draining.  Moreover,  by  its  use  we 
avert  the  danger  of  weakening  the  abdominal  walls,  and  thus  favoring 
the  occurrence  of  a  hernia  by  delay  in  union  at  any  point.  The  only 
objection  to  be  raised  against  the  vagina  as  a  canal  for  drainage  is  the 
fact  that  antisepsis  is  rendered  more  difficult  by  the  large  number  of 
micro-organisms  always  present  in  the  genital  tract. 

Without  dwelling  upon  inefficient  or  complicated31  methods  of 
drainage,  I  shall  describe  the  one  that  seems  to  me  of  the  most  value. 
It  consists  in  the  introduction  of  a  cross-shaped  tube  formed  of  two 
rubber  tubes  firmly  united.  (This  may  be  done  with  silk  sutures,  but 
there  is  danger  of  secondary  infection.)  After  a  laparatomy  this 
tube  may  be  inserted  through  an  incision  in  the  posterior  cul-de-sac, 
or  directly  by  puncture  with  a  large  trocar,  or  better  still,  with 
TVolfler's  forceps. 

I  have  seen  them  inserted  by  A.  Martin  without  previous  puncture 
of  the  tissue,  the  transverse  arms  of  the  tube  were  held  folded  in  the 
teeth  of  the  forcers — the  surgeon  placed  two  fingers  in  the  pouch  of 
Douglas,  and  while  the  cervix  was  held  down  by  an  assistant,  who  at 
the  same  time  administered  a  vaginal  antiseptic  injection,  the  opera- 
tor forcibly  pushed  the  forceps  behind  the  cervix  into  the  posterior 
cul-de-sac,  bursting  through  its  walls  and  carrving  the  tube  into  the 


72 


CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 


abdomen  between  the  guiding  and  supporting  fingers.  The  inventor 
of  this  process  claims  that  rapidity  of  action  is  secured  and  danger  of 
hemorrhage  or  of  wounding  the  rectum  is  averted.  For  my  part  I 
prefer  the  cautious  use  of  Wolfler's  forceps  (Fig.  52).     The  transverse 


Fig.  52.— 1,  Rubber  cross-shaped  drainage  tube  for  draining  cavities;  2,  method  of  seizing  the  tube  in 
the  forceps  for  insertion  in  a  cavity;  3,  Wolfler's  forceps  for  introducing  tubes  by  transfixion. 

arm  of  the  tube  is  held  securely  in  place  and  yet  in  such  a  way  that 
it  can  be  taken  out,  when  necessary,  by  strong  traction.  The  vaginal 
extremity  should  be  wrapped  in  iodoform  gauze.  Unless  special  in- 
dications call  for  longer  drainage,  it  is  left  in  place  eight  or  ten  days 


METHODS    OF   SUTURE   AND   HJEMOSTASIS. 


73 


at  most.  A  feeling  of  discomfort  in  the  abdomen  warns  as  when  the 
tube  ceases  to  be  tolerated.  As  a  matter  of  prudence,  it  is  better  to 
administer  no  injections  either  through  the  tube  or  in  the  vagina 
while  the  tube  is  in  place;  exuded  fluids  can  be  absorbed  by  gently 
pushing  iodoform  gauze  into  the  vagina.32 

Drainage  through  the  abdominal  walls  has   hitherto   been  done 

,  ,"■'.,' !..\0..:,: .<4*.>>«:.v  ■':■■<.   ■■■■  ■»'■'   '  "■ 

I: ■,-.""  ■■,■■'■■■'■■:■ ■■■C|-v".  -j'-',  &~-  $■■  :^::^--;Wv    ;.'..■. 


Fig.  53.— Tubes  for  Peritoneal  Drainage;  1,  Koeberle's  tube ;  2,  Keith's  tube. 

chiefly  with  glass  tubes.  It  is  advisable  to  have  an  opening  only  at 
the  inner  end.  This  is  inserted  into  the  cul-de-sac  of  Douglas  and  the 
upper  extremity  emerges  from  the  abdomen  into  an  absorbent  dress- 
ing. Lawson  Tait  uses  a  special  sort  of  cupping-glass  to  pump  out 
fluid.  Koeberle,33  as  early  as  1867,  filled  the  canula  with  pledgets  of 
carbolized  cotton  to  absorb  the  fluid.     Hegar 34  adopted  this  process, 


Fig.  54. — Tact's  Cupping  Glass  for  the  Aspiration  of  Fluids  through  a  Glass  Drainage  Tube. 

with  improvements,  bringing  into  play  the  capillarity  of  the  absorp- 
tive substances  contained  in  the  canula,  which  were  frequently  renewed. 
He  finally  changed  the  canula  into  a  large  abdominal  speculum  (Bauch 
speculum)  of  glass  or  hard  rubber,  one  or  two  inches  in  diameter  and 
seven  inches  long,  filled  in  his  earlier  experiments  with  carbolized 
cotton,  later  with  iodoform  gauze.  On  the  first  day  this  is  renewed 
every  hour,  then  every  two  hours,  and  finally  every  four  hours.  Hegar 
has  since  abandoned  this  method  for  that  of  capillary  drainage  by 


74  CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 

means  of  iodoform  gauze  only.  It  is  evident,  then,  that  capillary- 
drainage  has  for  some  time  been  an  auxiliary  to  tubular  drainage 
through  an  abdominal  opening;  it  counteracts  the  injurious  effects  of 
pressure  far  better  than  Nussbaum* s  method  of  turning  the  patient 
upon  the  side  or  the  abdomen.  The  credit  of  reducing  to  a  system 
what  was  previously  a  more  or  less  empirical  process,  is  due  to 
Kehrer.35  He  proposed  the  use  of  lamp-wick  about  as  thick  as  the 
little  ringer,  thoroughly  disinfected  by  boiling  in  a  five-per-cent  car- 
bolic solution;  in  practice,  however,  it  is  usual  to  immerse  the  wick 
in  iodoform  ether,  and  then  thoroughly  dry  it. 

Since  the  publication  of  Kehrer's  article,  antiseptic  lamp-wick,  iodo- 
formed  or  carbolized,  has  been  extensively  used  in  Germany,  both  in 
gynaecological  operations  and  in  general  surgery.  Breisky  has  long 
used  it  for  drainage,  after  vaginal  hysterectomy  for  uterine  cancer. 
Billroth  used  it  for  several  purposes,  but  seems  now  to  prefer  strips 
of  iodoform  gauze.  Nevertheless  the  lamp-wick  has  recently  come 
into  favor  again.  Gersuny36  considers  its  absorptive  powers  greater 
than  those  of  gauze,  and  Chrobak 37  took  the  trouble  to  demonstrate 
its  superiority  by  means  of  comparative  experiments.  He  used  it  in 
draining  after  ovariotomy  and  supra- vaginal  hysterectomy.  Yet  oper- 
ators of  no  less  authority  than  Hegar,  Mikulicz,  etc.,  affirm  that  the^ 
absorptive  powers  of  gauze  are  all  sufficient,  and  that,  other  things 
being  equal,  it  is  best  to  avoid  multiplying  the  number  of  materials 
used  for  dressings.  The  indications  for  simple  capillary  drainage  of 
the  peritoneum,  as  distinguished  from  the  combination  of  it  with  tam- 
poning, to  which  I  shall  shortly  allude,  are,  I  believe,  very  few.  For 
my  part,  I  use  it  only  after  vaginal  hysterectomy.  Instead  of  insert- 
ing one  or  two  tubes  into  the  peritoneal  opening,  or  leaving  it  quite 
open  as  do  many  surgeons,  I  prefer  to  reduce  the  size  of  the  wound 
by  a  few  lateral  sutures  and  push  in,  to  the  depth  of  about  a  finger,  a 
large  strip  of  iodoform  gauze  doubled  upon  itself,  its  two  ends  tucked 
into  the  vagina  and  easily  recognized  by  a  thread  tied  about  them. 
At  varying  intervals,  depending  upon  the  amount  of  exudation,  the 
other  pieces  of  iodoform  gauze  which  complete  the  intra- vaginal  dress- 
ing are  renewed,  but  the  strip  in  Douglas'  pouch  is  left  in  place  as  a 
drain  and  only  removed  after  a  lapse  of  six  or  eight  days. 

Antiseptic  Tamponade  of  the  Peritoneum.— It  was  a  bold  step  to 
stuff  antiseptic  pledgets  into  a  portion  of  the  peritoneal  cavity  so  as 
to  isolate  it  from  the  remainder  of  the  serous  membrane.  This  isola- 
tion is  produced  in  the  first  few  hours  by  the  tampon  barrier  alone,. 


METHODS    OF   SUTURE   AND   ELEMOSTASIS.  75 

later  by  the  adhesions  formed  at  its  periphery.  This  audacious  pro- 
ceeding was  suggested  by  the  success  following  the  tamponade  of 
wounds  which  replaced  drainage  in  Kocher  and  Bergmann's  practice.38 
The  second  step  was  Hegar's s9  use,  in  the  opening  of  pelvic  abscess,  of 
a  process  founded  upon  Volkmann's  method  of  opening  hepatic  ab- 
scess. Finally  tamponade  of  the  peritoneum  itself  was  recommended 
by  Mikulicz.40  It  has  been  used  in  Germany  and  in  America,41  but  I 
can  find  no  record  of  its  use  in  England,  and  in  France 42  I  was  the 
first  to  describe  and  make  use  of  it. 

Method  of  Application. — Mikulicz  advises  the  insertion,  in  the 
first  place,  in  the  cavity  to  be  tamponed,  of  a  pocket  formed  by  stuff- 
ing in  a  piece  of  20$  iodoform  gauze.  To  the  centre  of  this  piece  of 
gauze  is  attached  an  antiseptic,  double  silk  thread  by  means  of  which 
it  may  later  be  withdrawn.  To  save  time,  this  should  be  arranged 
before  the  operation ;  the  gauze  when  in  place  looks  like  a  tobacco 
pouch ;  five  or  six  long  strips  of  iodoform  gauze  are  now  stuffed  in 
and  spread  over  the  whole  surface  of  the  cavity,  their  ends  project 
from  the  gauze  pouch,  and  with  it  emerge  from  the  lower  extremity 
of  the  abdominal  wound  (Fig.  55).  This  process  may  be  simplified  by 
merely  pushing  the  strips  of  gauze  directly  into  the  cavity,  if  that 
cavity  be  small  or  tortuous — but  one  must  take  care  that  the  gauze 
has  no  loose  threads  upon  its  edges. 

It  is  well  to  insert  a  large  drainage  tube  at  the  same  time;  this 
will  give  central  support  to  the  tamponing  and  prevent  the  accumula- 
tion below  of  fluids  too  dense  to  filter  through  the  gauze. 

I  also  advise  that  all  iodoform  powder  be  removed  from  the  gauze 
by  thoroughly  beating  it,  for  I  have  occasionally  seen  signs  of  mild 
iodoform  poisoning.  It  is  well,  also,  to  attach  threads  of  different 
color  to  the  various  strips  of  gauze,  so  as  to  know  which  ones  to 
take  out  first. 

How  long  should  the  tampons  be  left  in  place  ?  Mikulicz  says  the 
strips  of  gauze  should  not  be  removed  under  forty-eight  hours,  and 
the  bag  itself  three  or  four  days  later.  One  should  be  guided  by  the 
amount  of  oozing,  and  the  condition  of  the  j>arts  to  which  tampons 
have  been  applied.  At  all  events,  the  pouch  should  not  be  taken  out 
before  the  fifth  day,  so  that  the  peripheric  adhesions  may  become  firm 
enough  to  be  safe  from  all  danger  of  tearing.  It  is  easy  enough  to 
remove  the  strips  of  gauze,  if  you  follow  my  advice  and  put  on  some 
mark  by  which  they  may  be  distinguished  and  removed  in  consecu- 
tive order.     Otherwise  their  extraction  may  be   difficult  and  cause 


73 


CLINICAL   AND    OPERATIVE   GYNAECOLOGY, 


injury.  Gluck  has  recently  proposed  the  use  of  tampons  which  can 
be  absorbed,  as  catgut,  etc.  This  seems  to  me  a  theoretical  idea  in- 
capable of  practical  application.43  Though  it  be  necessary  to  leave 
the  tampons  in  place  long  enough  to  permit  of  the  formation  of 
plastic,  aseptic  inflammatory  adhesions  surrounding  and  circumscrib- 
ing it,  it  is  self-evident  that  the  external  dressings  should  be 
changed  as  often  as  necessary — or  about  three  times  a  day.  The 
serum  secreted  at  the  depth  of  the  wound  and  transmitted  by  capil- 


Fig.  55.— Tamponade  of  the  Peritoneal  Cavity  after  Hysterectomy,    a  a,  Pouch  of  iodofor     gauze  ; 
b,  silk  thread  fastened  to  centre  of  pouch ;  c  c,  strips  of  iodoform  gauze. 

lary  drainage  through  the  tampons  is  very  rapidly  absorbed  by  this 
external  dressing. 

It  is  no  more  possible  to  lay  down  an  absolute  rule  in  reference  to 
cases  demanding  the  use  of  tampons  than  it  was  in  the  case  of  drain- 
age. Much  is  necessarily  left  to  the  judgment  of  the  operator.  Tam- 
ponade should  certainly  be  reserved  for  exceptional  use,  an  ultima 
ratio,  either  for  parenchymatous  oozing  (hemostatic  tamponade)  or 
in  case  of  threatened  septic  infection  (protective  antiseptic  tampon- 
ade).    In  the  latter  case,  two  different  conditions  may  exist. 


METHODS    OF   SUTURE   AND    H^EMOSTASIS. 


77 


A.  A  part  of  the  wound  is  already  septic  at  the  time  of  operation, 
and  on  account  of  the  presence  of  septic  tissue  which  cannot  be  re- 
moved without  danger,  or  of  the  large  effusion  of  pus  and  septic  fluid, 
irrigation  and  cleansing  seem  to  produce  no  effect. 

B.  The  danger  of  infection  occurs  after  closure  of  the  abdominal 
wound,  and  is  due  to  the  falling  apart  of  a  badly-made  suture,  or  to 
perforation  of  some  organ  affected  before 
or  by  the  operation  (intestines,  bladder). 
In  either  case,  I  have  obtained  good 
results  from  an  antiseptic  tamponade. 
[This  method  is  also  valuable  and  most 
often  used  in  cases  where,  for  any  reason, 
such,  as  the  presence  of  universal  adhe- 
sions or  because  of  anatomical  relations, 
it  is  impossible  to  complete  the  removal 
of  any  abdominal  or  pelvic  cyst.  In  these 
cases,  after  stripping  off,  if  possible,  the 
lining  membrane  of  the  sac,  the  cavity  is 
stuffed,  as  described,  with  an  iodoform 
gauze  pouch  filled  wTith  plain  gauze  to 
lessen  the  risk  of  iodoform  poisoning. 
This  is  allowed  to  remain  in  situ  for  from 
forty-eight  to  sixty -four  hours  or  longer 
if  there  be  no  rise  of  temperature,  when 
it  is  removed  and  the  cavity  repacked 
if  necessary.  The  cyst  cavity  rapidly 
shrinks  and  soon  becomes  a  granulating 
surface,  which  after  a  time  becomes  oblit- 
erated.] 

Intra-uterine  Drainage.  —  Capillary 
drainage  of  the  uterus  by  means  of  thin 
strips  of  iodoform  gauze  successively 
pushed  into  place  with  a  sound,  is  used  as  a  preventive  of  infection  from 
uterine  catarrh.44  These  strips  are  removed  at  the  end  of  twenty- 
four  hours  and  replaced  with  fresh  gauze,  a  procedure  easily  accom- 
plished because  of  the  increased  dilatation  of  the  cavity.  Should  the 
uterine  cavity  need  thorough  disinfection,  the  drainage  or  tamponing 
may  be  conducted  in  a  very  similar  manner  to  that  which  I  have  de- 
scribed for  the  peritoneal  cavity. 

Langenbuch,  Theide,  and  Schede  have  used  a  drainage-tube  closed 


¥ 


Fig.  56. — 1.  Apparatus  Connected  with 
a  Cross-tube  for  Continuous  Irrigation  of 
the  Uterine  Cavity  or  Vagina  ;  2.  Schiick- 
ing"s  Minim-dropper. 


78  CLINICAL   AND    OPERATIVE   GYNECOLOGY. 

at  the  upper  extremity,  but  perforated  with  holes  in  the  intra-uterine 
portion.  By  its  aid  one  can  make  frequent  injections  into  the  uterus, 
but  it  is  a  mistake  to  think  that  the  mucus  will  be  carried  off.  It  is 
too  thick  to  go  through  the  small  apertures;  the  tube,  moreover,  is 
kept  in  place  with  difficulty.  It  is  a  bad  method,  and  may  even  cause 
intra-uterine  infection  instead  of  preventing  it.  The  case  is  altered 
when  the  uterus  is  sufficiently  dilated  to  allow  of  the  insertion  of  a 
large  cross-tube,  which  is  a  far  better  instrument  than  the  metallic 
ones  which  have  been  recommended  (Sevastopoulo)  but  which  are 
likely  to  injure  the  "uterus.  It  is  both  easier  to  introduce  and  keep 
in  place,  and  safer  in  its  use ;  and  is  of  especial  value  when  a  perma- 
nent source  of  infection  exists  in  the  dilated  uterus,  as  a  sloughing 
shred  from  a  fibroid,  or  a  piece  of  foetal  membrane  which  has  evaded 
curetting.  When  necessary,  this  drainage  can  precede  continuous 
irrigation,  and  in  any  case  it  facilitates  the  evacuation  of  concealed 
fluids  and  the  frequent  administration  of  intra-uterine  injections. 

Continuous  Irrigation. — The  following  is  my  method  of  applying 
it: 

The  arms  of  the  crossed  drainage  tube  are  doubled  up  in  the  for- 
ceps and  inserted  (Fig.  52,  2)  into  the  uterine  cavity,  which  having 
already  been  dilated,  offers  no  obstruction.  As  a  preliminary,  you 
rapidly  introduce  two  or  three  pints  of  a  strong  antiseptic  solution 
(3 : 1,000  of  carbolic,  \\  1,000  of  bichloride),  then  begin  the  irrigation  to 
the  full  capacity  of  the  canal,  and  finally,  drop  by  drop,  either  by  the 
use  of  an  ordinary  stop-cock,  or  Schucking's  minim-dropper.  The 
solution  used  should  now  be  weaker  (ten  per  cent  carbolic,  one- 
fiftieth  per  cent  bichloride),  and  should  be  maintained  at  a  tempera- 
ture of  95°  to  100°  F.  This  drainage  and  irrigation  may  be  left  in 
place  several  days,  but  should  be  removed  every  two  hours  and 
cleansed  (Fig.  56). 

The  patient  is  to  be  kept  upon  a  rubber  apparatus  or  sheet  so  ar- 
ranged as  to  carry  the  fluid  into  a  receptacle  placed  upon  the  floor 
by  the  bedside  (Figs.  5  and  6).  The  buttocks  and  genital  organs  are 
to  be  anointed  with  vaselin  to  prevent  excoriation.45 

Antiseptic  tamponade  of  the  uterine  cavity  was  first  used  by 
Fritsch 40  in  the  dressing  of  certain  cancers  of  the  body  of  the  uterus, 
and  has  proved  of  use  to  me  in  similar  cases.  Long  strips  of  iodo- 
form gauze  are  prepared  and  gently  pushed  into  the  uterus  with  some 
"blunt  instrument,  as  long  and  slightly-curved  forceps,  being  packed 
in  gradually,  somewhat  as  a  tooth  is  filled  (to  use  Fritsch's  expres- 


METHODS    OF   SUTURE   AND   BLEMOSTASIS.  Id 

sion).  The  gauze  may  be  left  in  place  from  three  to  six  days,  and 
renewed  from  time  to  time  until  the  disinfection  is  thoroughly  ac- 
complished. Intra-uterine  tamponade  may  be  haemostatic  as  weJl  as 
antiseptic;  it  is  then  well  to  use  a  gauze  which  is  prepared  with  resin 
us  well  as  iodoform:  this  can  be  made  upon  the  spot  when  necessary 
by  thoroughly  dusting  some  Lister's  gauze  with  iodoform  powder. 
Very  exceptionally  one  may  add  a  few  drops  of  the  perchloride  of 
iron  after  curetting  a  cancer  or  enucleating  a  fibroid.  Such  a  tam- 
ponade, jDreceded  by  hot  injections,  and  followed  by  the  administration 
of  ergot,  may  be  of  inestimable  value.  It  has  recently  been  applied 
to  post-abortum  and  post-partum  hemorrhages,  and  used  in  the  treat- 
ment of  uterine  atony.47 

Tamponade  of  the  Vagina. — This  must  not  be  confounded  with 
the  mere  insertion  of  tampons.  To  deserve  the  former  appellation, 
the  vagina  should  be  filled  through  its  whole  extent  with  a  column  of 
a  more  or  less  elastic  substance — lint,  cotton,  gauze,  or  wool — rendered 
aseptic  and  antiseptic  by  previous  treatment.  Various  medicinal 
agents  may  be  incorporated  with,  it,  but  the  tamponing  is  the  chief 
object  in  view. 

It  may  be  used  for  two  different  puiptoses.  1.  Haemostatic;  2. 
antiphlogistic. 

1.  Hcemostatio  Tamponade. — This  is  not  a  method  adopted  from 
choice,  but  from  urgent  necessity,  a  profuse  metrorrhagia  calling  for 
immediate  interference.  To  seek  the  cause  and  treat  it  directly  is 
always  best,  but  not  always  possible,  and  to  gain  time  we  resort  to 
vaginal  tamponade,  inserting  below  the  os  uteri  a  large  pledget  of 
-cotton  which  is  permeated  with  great  difficulty,  and  causes  coagula- 
tion of  the  blood  in  the  uterus.  Emmet,  to  attain  the  same  object, 
lias  had  recourse  to  temporary  suture  of  the  external  os.  We  must 
not  forget  that  this  is  an  expedient  merely,  and  not  treatment  prop- 
erly so  called ;  danger  would  attend  its  protracted  use,  either  from 
the  hemorrhage  itself,  or  from  reflex  reactive  action  caused  by  the 
foreign  body  in  the  vagina.  But,  bearing  in  mind  the  possibility  of 
such  an  occurrence,  the  method  is  capable  of  rendering  good  service. 

The  old  way  of  tamponing  consisted  in  the  introduction  through 
a  cylindrical  or  bivalve  speculum  of  dry  lint,  arranged  something  like 
a  kite-tail.  This  lint,  filled  with  germs,  was  often  left  in  place  long 
enough  to  initiate  infection.  Since  the  era  of  antisepsis,  lint  has 
been  replaced  by  cotton  or  gauze  saturated  with  carbolic,  salicylic,  or 
boric  acid,  bichloride  or  iodoform.     These  materials  are  not,  how- 


80  CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 

ever,  of  equal  value;  dry  absorbent  cotton  is  even  injurious  owing  to 
its  permeability;  well-packed  gauze  is  so  in  a.  less  degree,  yet  pro- 
ductive of*  harm  unless  previously  well  moistened. 

That  this  little  operation  may  be  effective,  I  advise  the  following 
mode  of  procedure,  bidding  you  bear  well  in  mind  that  its  use  is 
rarely  called  for  except  in  cases  where  life  is  endangered.  We  first 
assure  ourselves  that  the  rectum  and  bladder  are  empty.  The  best 
position  for  exposure  of  the  whole  vagina  without  fatigue  to  the 
patient,  is  the  Sims'  or  lateral  semi-prone  position.  The  blade  of  a 
speculum  depresses  the  posterior  wall,  and  the  entrance  of  air  brings 
the  parts  into  view.  Irrigation  with  carbolized  1$  solution  will  clear 
out  clots  and  accumulated  blood.  For  the  tamponade  I  recommend 
the  use  of  pledgets  of  cotton,  a  few  of  them  saturated  with  a  concen- 
trated solution  of  alum,  the.  greater  number  with  the  weak  carbolic 
solution  which  has  been  used  for  irrigation.  Just  before  using  them, 
they  are  squeezed  into  the  shape  of  flat  discs  about  the  diameter  of  a 
silver  dollar  and  twice  or  three  times  as  thick.  With  long  forceps, 
five  or  six  of  the  alum  discs  are  rapidly  packed  around  the  cervix  in 
the  culs-de-sac,  down  to  the  level  of  the  external  os.  When  this  is 
covered  over,  the  tamponing  is  continued  with  the  carbolized  discs, 
squeezed  as  dry  as  possible. 

It  will  be  necessary  to  have  a  large  number  of  these  cotton  pledgets, 
though  they  are  not  to  be  forcibly  pressed  into  place,  but  simply  in- 
serted one  upon  the  other  so  as  to  form  a  homogeneous  mass.  The 
speculum  is  gradually  withdrawn  as  the  discs  are  introduced,  and 
will  be  entirely  free  just  before  the  completion  of  the  tamponing.  As 
this  cotton  column  may  compress  the  neck  of  the  bladder,  it  may  be 
necessary  to  use  the  catheter  from  time  to  time.  The  tampons  should 
not  be  left  in  place  more  than  twenty -four  hours ;  after  their  removal 
a  hot  douche  is  administered,  and  the  tamponade  is  only  repeated  if 
absolutely  necessary. 

B.  Antiphlogistic  Tamponade. — The  results  aimed  at  by  the  in- 
ventors of  the  process  of  columning  the  vagina  are:  the  mechanical 
uplifting  of  the  uterus  by  relaxing  the  strain  upon  its  ligaments, 
diminution  of  venous  stasis  due  to  its  prolapse,  the  slowing  of  the 
arterial  current  by  eccentric  pressure  on  the  parts;  combating  thus 
congestion  and  inflammation  and  bringing  the  tissues  into  a  favorable 
condition  for  the  reabsorption  of  exudations,  and  the  cessation  of 
pathological  reflex  phenomena.  Bozemann 48  seems  to  have  been  the 
first  to  use  both  the  name  of  "  columning  "  and  the  process.     Talia- 


METHODS   OF   SUTURE   AND   ELEMOSTASIS.  81 

ferro 49  was  the  one  to  introduce  it  into  general  tise.  It  is  a  popular 
method  of  treatment  in  America,50  and  the  happy  results  obtained 
prove  that  it  is  worthy  of  serious  consideration  as  a  therapeutic  mea- 
sure, especially  in  the  case  of  subacute  or  chronic  perimetritis,  sub- 
involution, etc.  The  following  is  the  correct  method  of  procedure. 
The  best  position  in  which  to  place  the  patient  is  the  genu-pectoral; 
this  permits  of  free  access  to  the  vagina,  which  is  opened  out  by  the 
in-rushing  air.  [This  position  is  a  disagreeable  one  for  the  patient, 
and  practically  equally  good  results  may  be  obtained  in  the  Sims' 
position.]  One  should  have  at  hand,  1st,  small  pledgets  of  antiseptic 
absorbent  cotton,  soaked  in  glycerin  and  squeezed  dry,  2d,  pieces 
of  fine  wool,  purified  in  a  sterilizing  oven,  washed  in  a  lfo  carbolic 
solution  and  wiped'  dry;  this  substance  is  employed  because  of  its- 
elasticity.  A  tamponade  composed  entirely  of  absorbent  cotton  would 
be  too  compact ;  cotton  from  which  the  oil  has  not  been  expressed, 
although  less  elastic  than  wool,  may  conveniently  replace  it  if  neces- 
sary. Tampons  or  discs  to  be  used  are  soaked  in  glycerin  and 
squeezed  out,  then  inserted  in  the  posterior  cul-de-sac,  and  surround 
the  cervix,  holding  it  firmly  in  place.  The  packing  of  the  vagina  is 
completed  by  filling  it  with  well-carded  wool  or  non-absorbent  cotton 
almost  to  the  vulvar  opening.  The  patient  should  keep  her  bed  for  one 
or  two  days  after  the  first  tamponing,  which  is  always  applied  more 
compactly  than  those  which  follow.  Should  an  erythema  super vener 
it  would  be  well  to  use  only  dry  substances  well  covered  with  vaselin. 
The  tamponade  is  renewed  every  two  or  three  days,  and  to  be  effectual 
should  be  persisted  in  for  several  consecutive  weeks  or  months. 

One  may  produce  a  topical  effect  upon  the  vaginal  mucous  mem- 
brane by  saturating  the  cotton  or  the  wool  with  medicinal  agents,  as 
glycerole  of  tannin,  etc.,  but  when  this  is  done,  tamponing  ceases  to 
be  tamponade  and  becomes  merely  a  collection  of  tampons. 

BIBLIOGRAPHY. 

1.  Hegar  and  Kaltenbaeh  :   Traits  cle  Gyn.  Operat.,  p.  140. 

2.  See  Discussion  Soc.  de  Chir.  de  Paris.     Bull.,  1888,  page  51. 

3.  Werth  :  Centr.  f.  Gyn.,  1879,  No.  27.  Marcy :  The  Perineum,  Phil.,  1889, 
page  28. 

4.  Tillmans,  Bako,  Hagedorn :  Cent,  f.  Chir.,  1882,  No.  37. 

5.  Broese  :  Die  forth  Katgutnaht  zur  Yereinigung  der  Scheiden-Damrurisse. 
Centr.  f.  Gynak.,  1885,  p.  777. 

6.  S.  Pozzi ;  Note  sur  la  Suture  Perdue,  etc.  Congres«Francais  de  Chirurgier 
1888,  p.  575. 

7.  Yon  Hacker  :  Wien.  rued.  YvToch..  No.  48,  1885. 

-    6 


82  CLINICAL   AND    OPEEATIVE   GYNAECOLOGY. 

8.  Wallich  :  Sur  la  Ligature  en  Chaine,  Proc^de  pour  placer  les  Fils.  Annales 
de .Gyri(?cologie,  Nov.,  1888. 

9.  J.  W.  Long  :   A  New  Stitch.     Amer.  Journal  of  Obstetr.,  p.  133,  Feb.,  1888. 

10.  Marcy :  Jour.  Amer.  Med.  Ass.,  July  24th,  1888. 

11.  Putiboff  :   Russische  Med.,  No.  5,  1884. 

12.  Virchow's  Archiv,  vol.  lxxviii. 

13.  Experimentelle  Untersuchungen,  etc.     Centr.  f.  Gyn.,  No.  24,  1889. 

14.  Kaltenbach  :   Die  operat.  Gynec,  3d  ed.,  p.  268. 

15.  Heppner  :   Petersburg  Med.  Zeitschr.,  1870,  xvii.,  p.  306. 

16.  Bull,  de  Soe.  de  Chir.,  1886,  pages  198  and  201. 

17.  Walcher  :  Klammer  zur  Erleichterung  der  Anlegung  der  elastischen  Ligatur. 
Centralblatt  fur  Gnyak.,  1884,  No.  52. 

18.  Koeberle' :  De  l'Hemostase  Definitive  par  Compression  Excessive,  Paris, 
1877. 

19.  Revillout :  Gaz.  des  Hopitaux,  No.  75,  p.  297,  1868. 

20.  Koeberle'  :  Gaz.  des  Hopitaux,  page  419,  1868. 

21.  Du  Pineementdes  Vaisseaux  comme  Moyen  d'H^moatase.  Lecons  Extraites 
du  tome  ii.  des  Cliniques  Chirurgicales,  Paris,  1877. 

22.  Ovariotomie  et  Splenotomie,  Paris,  1869,  page  51. 
53.  Bull,  et  Mem.  de  la  Soc*  de  Paris,  vol.  i.,  1875. 

•.24.  For  the  history  of  forcipressure  and  the  question  of  prior  claims  to  its  in- 
dention consult,  in  addition  to  the  works  already  quoted  :  Koeberle  :  Bull,  et  Mem. 
de  la  Soc.  de  Chir.  de  Paris,  vol.  ii.  (new  series),  1876,  p.  767,  and  Epilogue,  Paris, 
1877.  Gross :  Les  Pinces  H£mostatiques  des  Docteurs.  Koeberle  et  P6an  et  la 
Forcipressure.  Revue  m6dicalede  l'Est,  1876.  Deney  and  Exchaquet :  De  la  Forci- 
pressure ou  de  F  Application  des  Pinces  a  l'Hemostasie  Chirurgicale,  Paris,  1875. 
Pean:  Comptes  Rendu s,  Memoireset  Discussions  du  Congres  Francais  de  Chirurgie, 
1886,  p.  388. 

25.  Spencer  Wells  :  Remarks  on  Forcipressure  and  the  Use  of  Pressure  Forceps 
in  Surgery.     Brit.  Med.  Jour.,  vols.  i.  and  ii.,  1879. 

26.  Spencer  Wells  :   Ovarian  and  Uterine  Tumors. 

27.  C.  E.  Jennings  :   The  Lancet,  1886,  vol.  i.,  pages  682  and  825. 

28.  See  also  S.  Pozzi :   Ann.  de  Gyn.,  Aug.,  1888. 

29.  Chenieux  :  Comptes  Rendus  du  Congres  Francais  de  Chirurgie,  1886. 

30.  Arch.  f.  klin.  Chir.,  vol.  xx.,  page  51,  1876.  See  also  Edler :  Die  traumat. 
Verletz.  der  parench.  Unterleibes-Organe.    Arch,  fur  klin.  Chirurg.,  page  198,  1886. 

31.  Drainage  by  means  of  a  simple  tube  may  be  termed  inefficient ;  that  in- 
vented by  Bardenheuer  is  a  good  example  of  a  complicated  method  :  Zur  Frage 
der  Drainirung  der  PeritonealhOhle,  Stuttgart,  1885. 

32.  Martin  :  Path,  und  Ther.  der  Frauenkrankh. ,  2d  ed.,  1887,  page  374.  Samm. 
klin.  Vortr.,  No.  219.     Berl.  klin.  Woch.,  No.  5,  1885. 

33.  Vautrin  :  Du  Traitement  Chirurg.  des  Myomes  Uterins,  Paris,  1886,  p.  196. 

34.  Hegar  and. Kaltenbach  :  Die  operat.  Gynak.,  1st  German  ed.,  pp.  264  and 
265.  Hegar:  Centralbl.  f.  Gyn.  1882,  No.  7.  Wiedow :  Die  Drainage  der  Bauch- 
hOhle  and  das  Bauchspeculum.     Berliner  klin.  Wochensch.,  No.  39,  1884. 

35.  F.  A.  Kehrer:  Kapillardrainage  der  BauchhOhle.  Centr.  f.  Gyn.,  1882, 
No.  3. 

36.  Gersuny:  Centr.  f.  Chir.,  1887,  No.  31. 

37.  Chrobak :  Centr.  f.  Gyn.,  1888,  No.  1. 

38.  F.  Bramann  :  Ueber  Wundbehandlung  mit  Iodoformtamponade.  Arch. 
f.  klin.  Chir.,  Bd.  xxxvi.,  p.  72. 

39.  Wiedow:  Operat.  Behand.  der  Genital-Tuberc.  Centralbl.  fur  Gynak., 
September,  1885. 


METHODS   OF   SUTURE  AiSTD   H^MOSTASIS.  83 

40.  Mikulicz  :  U eber  die  Ausschaltung  der  todten  Rauine  aus  der  Peritoneal- 
hOhle,  etc.     Verhandl.  der  Deutsch.  Gesellschaft  f.  Chir.,  p.  18?  etseq.,  Berlin,  1886. 

41.  Christian  Fenger  :  The  Operative  Treatment  of  Retro-peritoneal  Cysts  in 
Connection  with  Mikulicz's  Method  of  Drainage.  The  Axuer.  Journ.  of  Obstetrics, 
p.  703,  July,  1887. 

42.  S.  Pozzi :  Drainage  Capillaire  et  Tauiponnement  Antiseptique  du  Peritoine. 
Bull,  de  la  Soc.  de  Chirurgie,  February  29th,  1888. 

43.  Ueber  resorbirbare  antisept.  Tamponade.  Deutsche  Med.  "VVoch.,  1888, 
No.  39. 

44.  Fritsch :  Die  Krankheiten  der  Frauen,  1886,  page  77  ;  and  Landau  :  Zur 
Erweiterung  der  Gebarniutter.     Deutsch.  Med.  Zeit.,  1887,  No.  93. 

45.  Consult  Fritsch  :  Die  Krankh.  der  Frauen,  1886,  p.  63.  Schultze  :  Die  pro- 
longate unddie  permanente  Irrigation.  Centr.  f.  Grynak.,  1888,  p.  414.  Sneguireff  : 
H6morrhagies  Uterines,  etc.  French  edition  by  H.  Varnier,  1885.  Pinard  and 
Yarnier  :  Annales  de  Gynecologie,  1885. 

46.  Fritsch  :  Samnilung  klin.  Yortrage,  No.  288. 

47.  A.  Diihrssen :   Centr.  f.  Gynak.,  No.  35,  Aug.  27th,  1887. 

48.  Quoted  by  James  H.  Etheridge  :  Gynaecol.  Soc.  of  Chicago,  February  17th, 
1887.     The  American  Journal  of  Obstetrics,  xx.,  p.  655. 

49.  V.  H.  Taliaferro  (of  Atlanta):  The  Application  of  Pressure  in  Diseases  of  the 
Uterus,  1878. 

50.  P.  F.  Munde :  Minor  Surgical  Gynaecology,  New  York,  1885,  p.  210.  Ethe- 
ridge :  Antiseptic  Tamponnement  of  the  Vagina  in  the  Treatment  of  Pelvic  Inflam- 
mation, Am.  Jour.  Obst.,  1887,  page  543.  Engelmann :  The  dry  Treatment,  etc.. 
Am.  Jour.  Obst.,  1887,  pp.  561,  685.  A.  Reeves  Jackson  :  Yaginal  Pressure  in  the 
Treatment  of  Chronic  Pelvic  Disease,  Am.  Jour.  Obst.,  1887.  p.  649.  Thomas  Adis 
Emmet :   New  York  Medical  Journal,  February  18th,  1888,  p.  169. 


CHAPTER   IT. 
METHODS   OF   GYNECOLOGICAL  EXAMINATION. 

The  chief  positions  in  which  we  are  called  upon  to  examine  pa- 
tients are  the  erect,  the  dorsal,  the  lateral,  and  the  genu-pectoral. 

Erect  Position. — The  vaginal  touch  with  the  patient  standing 
affords  only  limited  information,  but  is  useful  in  cases  of  displace- 


Fig.  57.— Metal,  Sheet  for  Continuous  Irrigation  QLourcine). 

ment  of  the  pelvic  organs  and  in  abdominal  tumors.  It  is  not  suitable 
for  comx>lete  examination  and  deserves  no  further  mention.  [I  cannot 
quite  agree  with  the  author  in  his  estimate  of  the  value  of  the  examin- 
ation in  the  erect  position.  Very  many  symptoms  of  pelvic  disease 
are  more  marked  or  only  noticed  when  the  patient  is  on  her  feet  and 
certain  conditions  of  descent,  prolapse,  or  displacement  may  entirely 
disappear  or  change  when  the  intra-abdominal  pressure  is  removed  in. 


METHODS   OF   GYNAECOLOGICAL   EXAMINATION. 


85 


the  dorsal  or  Sims'  position.  Further  a  pessary  which  seems  to  sup- 
port a  displaced  uterus  perfectly  while  the  patient  is  recumbent  may 
be  found  inadequate  when  she  is  erect.  As  these  conditions  cannot 
be  certainly  determined  in  any  other  manner,  the  value  and  often 
necessity  of  examination  in  this  position  is  evident.]  The  examiner, 
standing  mostly  in  front  of  the  j)atient,  places  his  left  knee  on  the 
floor  and  the  left  arm  back  of  the  patient's  waist,  while  the  right 


Fig   58  («  and  6)  —Kelly's  Ovariotomy  and  Perineal  Pads. 

knee,  semi-flexed,  supports  the  elbow  of  the  same  side  while  the  ex- 
amination is  progressing. 

Dorsal  Position.— Fot  an  examination  of  the  abdomen  or  the  sim- 
ple vaginal  touch  we  may  have  the  patient  lie  on  her  back,  with  her 
head  on  a  cushion,  the  legs  a  little  flexed  and  the  thighs  abducted. 
In  this  position  she  maybe  examined  provisionally  in  bed;  but  it 
does  not  produce  sufficient  relaxation  of  the  abdominal  muscles  to 
allow  satisfactory  palpation,  nor  does  it  permit  the  use  of  the  specu-  , 
lum. 

Modified  Dorsal  Position.— (Semi-recumbent  position.)  This  posi- 
tion, combines  the  advantages  of  relaxation  of  the  abdominal  mus- 
cles and  easy  examination  of  the  vagina  by  the  finger  or  the  spec- 


So 


CLIXICAL   AXD   OPEPwATIVE   GYNECOLOGY. 


ulum,  and  is  to  be  preferred  where  we  wish  a  complete  exploration. 
The  patient  is  placed  at  the  edge  of  a  bed  or  table;  the  upper  part 
of  the  body  is  a  little  raised,  as  if  the  woman  were  half  sitting; 


Fig.  59.— 1.  Triangular  basin  for  Dressings ;  2.  Basin  with  handle  ;  to  be  placed  under  patient  in  dorso- 
sacral  position. 

the  legs  are  flexed  upon  the  thighs,  and  they  in  turn  upon  the  abdo- 
men, and  are  held  in  this  position  by  the  assistants  or  with  the  aid 
of  foot-rests. 

Dorso-saoral  Position. — This  is  the  most  satisfactory  position  for 

all  operations  on  the  external 
genitals,  the  vagina  or  the  uterus 
per  vias  ndturales,  since  it  ren- 
ders all  these  parts  most  acces- 
sible to  the  surgeon.  The  pa- 
tient is  placed  at  the  edge  of  the 
bed  or  the  table;  the  head  is. 
elevated  by  a  pillow,  the  trunk 
is  horizontal,  the  pelvis  is  flexed 
upon  the  vertebral  column  so 
that  the  sacrum  presents  a 
marked  obliquity  both  vertically 
and  from  behind  forward.  The 
knees  are  bent  and  the  thighs 
strongly  flexed  over  the  abdo- 
men and  maintained  in  this  po- 
sition by  the  supports,  or,  better, 
by  the  assistants,  each  taking  the  flexed  knee  on  his  side  under  his 
axilla,  thus  leaving  the  hands  free  to  assist  the  operator.  If  one 
has  no  assistants,  the  ingenious  leg-rests  of  Fritsch  may  be  era- 
ployed,  in  combination  with  his  speculum  holder.  Many  forms  of 
leg-rest  have  been  invented ;  the  type  of  such  being  Clover's  crutch, 


Fig. 


-Patient  in  Modified  Dorsal  Position  on 
C'hadwick's  Table. 


METHODS    OF   GYNAECOLOGICAL   EXAMINATION. 


87 


which  has  been  ingeniously  modified  by  Ott  of  St.  Petersburg.2  A 
very  useful  modification  of  this  position  is  obtained  by  a  decided  ele- 
vation of  the  pelvis  above  the  rest  of  the  body;  a  position  which 
might  be  called  the  inclined  dorso-sacral.  This  tipping  of  the  pelvis 
has  the  effect  of  allowing  the  abdominal  contents  to  fall  toward  the 
concavity  of  the  diaphragm  and  renders  examination  of  the  true 
pelvis  very  easy.  For  a  simple  examination  this  position  is  easily 
obtained  by  letting  the  patient  lie  on  a  couch,  the  legs  flexed  over  the 
head -board,  which  serves  as  their  support.  If  one  has  assistants  at 
his  disposal,  he  may  let  them  turn  their  backs  and  take  each  a  leg  of 
the  patient  over  their  shoulders.  This  position  is  at  times  of  great  as- 


Fig.  61. — Ott's  Leg-Holder   (the  long  strap  is  fastened  to  the  table). 

sistance  to  the  operator,  in  freeing  the  pelvis  of  its  contents ;  as,  for 
instance,  in  examining  for  small  tumors  of  the  uterine  adnexa.  It 
has  been  recommended  by  Trendelenburg 3  in  searching  for  tumors  of 
the  bladder,  and  by  Pawlik  in  catheterizing  the  ureters ;  and  has 
lately  been  re-introduced  by  Mendes  de  Leon.4  To  render  explora- 
tion easy  and  the  organs  of  the  pelvis  accessible  during  laparatomy, 
it  has  been  found  equally  advantageous  to  allow  an  assistant  to  ele- 
vate the  uterus  by  two  fingers  in  the  vagina,  or  to  introduce  into  that 
canal  an  air-pessary — a  procedure  analogous  to  Petersen's  use  of  a 
balloon  during  lithotomy. 

[This  posture — the  Trendelenburg  position  with  the  pelvis  elevated, 
the  body  resting  upon  an  inclined  plane  at  various  angles  up  to 


S8 


CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 


45°  from  the  horizontal — is  now  employed  by  many  as  a  routine 
measure  during  the  performance  of  laparotomy ;  it  seems  to  possess 
no  disadvantages,   does  not  interfere  with  the  breathing,  renders 


Fig.  62.— Patient  in  Lithotomy  Position  with  Ott's  Leg-Holder. 

shock  from  acute  anaemia  less  liable,  besides  causing  the  intestines 
to  gravitate  toward  the  diaphragm  and  rendering  all  parts  of  the 


Fig.  63.— Cleveland's  Laparatomy  Table. 


pelvis  readily  accessible  both  to  touch  and  in  many  instances  to  sight, 
thus  lessening  markedly   the  technical   difficulties   of    intra-pelvic 

surgery.] 


METHODS    OF   GYNECOLOGICAL   EXAMINATION.  89 

Later  o-ahd  ami  in  d  or  Semi-prone  Positions. — This,  the  Sims  posi- 
tion, is  particularly  adapted  to  examinations  and  treatment  with  the 
duck-bill  speculum,  the  weight  of  the  abdominal  viscera,  drawing  for- 
ward and  upward,  neutralizes  the  intra-abdominal  pressure  and  causes 
an  easy  and  perfect  separation  of  the  vaginal  walls.  While  of  great 
use  in  many  different  circumstances,  it  is  particularly  desirable  with 
very  modest  patients. 

The  woman,  with  all  bands  about  the  waist  loosened,  should  lie 
upon  her  left  side,  at  the  edge  of  the  bed  or  the  table,  flexing  the  legs 


Fig.  64. — Cleveland's  Laparatomy  Table  Arranged  for  Trendelenburg's  Position. 

at  right  angles  with  the  thighs  and  these  at  the  same  angle  with  the 
body.  The  lower  extremities  may  be  held  by  an  assistant,  or  by  a 
support  fastened  to  the  table  (Fig.  67). 

The  patient's  body,  instead  of  resting  wholly  on  its  side,  is  so 
turned  that  her  chest  is  directed  obliquely  toward  the  table,  and  this 
is  best  accomplished  by  drawing  the  under  arm  out  behind  and  allow- 
ing it  to  hang  over  the  edge  of  the  table.  ["  In  this  j)osition  the 
woman  lies  partly  on  her  side  and  partly  on  her  chest  and  abdomen, 
the  abdominal  viscera  gravitate  forward  and  downward  away  from 
the  pelvic  cavity ;  the  pelvis  has  a  lateral  and  downward  inclination, 
so  that, a  line  drawn  from  the  coccyx  through  the  rima  vulvae  will 
strike  the  left  popliteal  space.     The  posterior  vaginal  wall  is  thus 


yo 


CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 


superior  to  the  anterior  and  the  uterus  sinks  downward  and  forward. 

For  ocular  examination  this  position  is  unrivalled  and  for  many  in- 
strumental and  operative  procedures  on  the  va- 
gina and  cervix  almost  indispensable.  While 
a  hard  table,  covered  with  a  blanket  or  lightly 
upholstered,  is  undoubtedly  the  best  couch  for 
this  position,  and  the  examination  is  facilitated 
by  giving  the  table  a  lateral  and  downward  in- 
clination toward  the  lower  side  and  head  of  the 
patient,  a  tolerably  satisfactory  examination 
may  be  made  on  a  firm,  level  sofa  or  bed,  which 
does  not  allow  the  hip  to  sink  into  the  level  of 
the  vulva.  The  table  should  be  so  placed  that 
the  light  falls  directly  upon  the  vulva  over  the 
right  shoulder  of  the  operator;  the  table  will, 
therefore,  occupy  a  diagonal  position  before  the 
window." 5] 
3.  Genu-Pectoral  or  Knee-chest  Position. — In  this  position  the 

body  rests  on  the  upper  chest  and  knees,  the  pelvis  being  the  highest 


Fig.  65.— Robb's  Leg-holder. 


Fig.  00.— Patient  in  Dorso-sacral  Position;  Showing  Application  op  Robb's  Leg-holder. 


point.     The  thighs  are  at  right  angles  to  the  pelvis,  the  knees  near 
the  edge  of  the  table  or  bed,  with  the  feet  projecting  over  its  edge; 


METHODS    OF   GYNAECOLOGICAL   EXAMINATION. 


91 


the  head  is  turned  and  rests  upon  the  side  of  the  face.  [All  clothing 
must  be  loose  about  the  waist.  In  this  position  the  weight  of  the 
abdominal  viscera  draws  strongly  upward  and  forward  (in  relation  to 
the  patient),  tending  to  displace  the  contents  of  the  pelvis  in  the  same 
direction,  and  as  soon  as  air  is  allowed  to  enter  the  vagina,  to  distend 
it  to  the  maximum.  For  these  reasons  it  is  extremely  valuable  in  the 
reposition  of  certain  retro-displacements,  particularly  of  the  gravid 
uterus,  or  in  freeing,  small  incarcerated  tumors.]  Patients  do  not 
readily  assume  this  position,  claiming  that  it  is  immodest,  but  in  cer- 
tain cases,  because  of  the  reversal  of  intra-abdominal  pressure  and  the 
vaginal  distention,  it  is  indispensable.     The  position  is  irksome,  cam 


Fig.  67.— Patient  in  Latero-abdominal  (Sims')  Position  on  Chadwice's  Table. 


not  be  long  maintained,  and  is  not  free  from  danger  if  used  during 
anaesthesia. 

4.  Genu-cubital  or  Knee-elbow  Position.— This,  vulgarly  known  as 
the  "  cow  "  position,  is  little  used  except  in  Bozeman's  operation  for 
vesico-vaginal  fistula.6  The  patient  rests  on  the  elbow  and  knees  and 
is  supported  by  special  apparatus  (see  figure  under  Vesico-vaginal 
Fistula).  Anaesthesia  in  this  position  is  somewhat  dangerous  because 
of  the  interference  with  respiration. 

Simple  Abdominal  Palpation. — The  patient  is  placed  in  the  dor- 
sal position  with  the  knees  a  little  bent,  and  advised  to  open  the 
mouth,  breathe  without  effort,  and  avoid  rigidity.  The  bladder  and 
rectum  should  be  empty,  and  it  is  well  to  completely  clear  the  large 


92 


CLINICAL    AND    OPEKATIVJS   GYNAECOLOGY^ 


intestine  beforehand  by  a  cathartic  and  an  enema.  Both  hands  are 
used  at  the  same  time.  They  should  be  warm,  for  when  cold  they 
excite  reflex  contractions.  Beginning  very  gently,  the  abdomen  can 
be  accustomed  to  the  manipulation  and  then  the  tips  of  the  fingers 
may  be  pressed  in  with  more  force  for  the  purpose  of  deeper  explora- 
tion. A  certain  amount  of  massage  disarms  the  abdominal  muscles, 
prevents  reflex  contractions,  and  permits  the  examiner  to  make  a  sat- 
isfactory palpation.7  It  is  advisable  to  proceed  methodically,  exam- 
ining the  hypogastric  region  and  then  the  iliac  fossae,  determining 
the  amount  of  alteration  in  the  internal  organs  from  their  normal  size 
or  position;  then  proceeding  to  the  umbilical  and  lumbar  regions, 
.and  finally  to  epigastric  and  hypochondriac.     The  normal  tension  and 


Fig.  i 


-Genu-pectoral  Position,  showing  the  Dilatation  of  the  Vagina  and  the  Falling  of  the 
Viscera  toward  the  Diaphragm. 


consistence  of  the  abdominal  walls  presents  marked  extremes.  The 
age  of  the  patient,  previous  pregnancies  or  multiparity,  leanness  or 
obesity,  the  distention  to  a  greater  or  less  extent  of  the  stomach  and 
the  intestine  from  gas  in  dyspeptics,  etc.,  are  all  conditions  which 
present  great  diversities  and  may  be  the  sources  of  error.  I  cannot 
pass  them  all  in  review,  but  will  mention  certain  ones. 

If  the  bladder  and  intestines  have  not  been  emptied,  one  is  not 
safe  against  the  illusion  that  there  is  a  tumor,  really  due  to  their  con- 
tents; and  at  all  times  too  great  confidence  must  be  avoided.  The 
soft  consistence  of  fsecal  matter  gathered  in  the  ca3cum  or  the  sigmoid 
flexure,  its  presence  in  the  lumbar  regions,  and  the  possibility  of 
making  a  dent  in  it  which  shall  persist,  as  in  clay,  are  all  characteris- 
tic qualities  which  will  disinguish  it  from  other  things.     But  even  a 


METHODS    OF   GYNAECOLOGICAL   EXAMINATION".  93- 

vigorous  cathartic  may  fail  to  remove  scybalous  masses  which  may 
have  accumulated,  especially  if  there  is  any  mechanical  cause  for  con- 
stipation. 

An  enormously-distended  bladder,  reaching  to  the  umbilicus,  has 
frequently  been  mistaken  for  a  cyst.  This  distention  may  be  due  to 
long  retentiou  and  incomplete  urination,  so  that  the  bladder  grad- 
ually assumes  an  unusual  size;  or  to  pressure  upon  the  vesical  neck;  or 
to  nervous  affections  which  lessen  sensibility.  I  was  once  summoned 
to  an  asylum  for  the  insane  to  puncture  an  ovarian  cyst,  which  proved 
to  be  nothing  but  extreme  vesical  distention  in  a  patient  with  general 
paralysis.  Therefore  always  pass  a  catheter  before  making  such  ex- 
aminations. 

Finally,  catheterism  if  rapidly  done  may  not  empty  the  bladder 
wholly.  There  are  cases  where  the  organ  is  bilobed,8  wallet-shaped, 
from  compression  between  a  pelvic  tumor  and  the  pubis,  and  the 
communication  between  the  two  portions  may  be  so  restricted  that 
the  stream  of  urine  ceases  when  the  lower  compartment  is  emptied. 
If  this  condition  be  suspected,  a  long  catheter,  which  should  be  of 
stiffened  rubber,  will  easily  relieve  the  difficulty  and  empty  the  upper 
portion.  It  thus  seems,  occasionally,  as  if  there  were  a  pseudo-cyst 
overhanging  a  veritable  tumor,  with  some  obscure  connection  between 
them.  The  recti  muscles  of  the  abdomen  often  simulate  tumors  by 
rigid  contractions  of  their  mass  and  the  sharpness  of  their  borders. 
Especially  is  this  true  when  there  is  a  separation  in  the  linea  alba 
with  lateral  displacement  of  the  muscles.  It  seems  also  that  there 
may  be  partial  contractions  between  two  tendinous  intersections, 
which  increases  the  difficulty  of  diagnosis. 

Meteorism  may  be  so  developed  that  it  resembles  either  a  tumor 
or  pregnancy.  In  this  case  percussion  gives  us  great  assistance  but 
does  not  remove  all  doubt;  there  have  been  cases  of  hysterical  meteor- 
ism which  have  deceived  the  most  distinguished  observers.9 

Extreme  obesity,  especially  of  the  flanks,  may  render  the  examin- 
ation very  uncertain.  I  have  often  observed  a  local  excess  of  adipose 
deposit  in  the  hypogastric  region  on  women  who  had  some  chronic 
disease  of  the  genital  organs,  as  one  often  sees  a  like  formation  over 
the  epigastrium  of  dyspeptics.  ,- 

Women  who  are  hyperaBsthetic,  or  cowardly,  and  consequently  be- 
come rigid  upon  even  the  slightest  touch,  require -.to  be  put  under  an 
anaesthetic  if  it  is  at  all  necessary  to  reach  a  decision  by  examination. 
It  is  possible  to  obtain  an  insight  into  the  patient's  condition  by  bi- 


94  CLINICAL   AND   OPEKATIYE   GYNECOLOGY. 

manual  palpation  which  far  exceeds  all  others  in  precision,  and  in  few 
cases  (except  where  there  is  unusual  flaccidity  or  leanness)  can  the 
ovaries  and  tubes  be  reached  by  abdominal  palpation  without  anaes- 
thesia. The  various  connections  of  a  tumor  cannot  be  exactly  de- 
termined without  such  aid.  Often,  for  instance,  a  tumor  which  ap- 
pears to  be  connected  with  the  uterus  while  the  patient  is  awake, 
becomes  easily  separable  under  anaesthesia;10  or  a  tumor  which  ap- 
pears hard  is  found  to  be  plainly  fluctuant. 

[Inspection. — Before  making  a  vaginal  examination  in  a  strange 
j)atient,  it  is  well  to  inspect  the  external  genitals  to  detect  the  pres- 
sure of  any  anomaly,  of  pediculi,  of  specific  or  other  nlcerations  or 
eruptions,  etc.] 

Vaginal  Touch. — The  clean  index  finger  is  first  covered  with  some 
antiseptic  lubricant  as  borated  vaselin,  or  carbolized  oil  and  is  then 
passed  into  the  vagina  with  a  motion  from  behind  forward,  gliding 
over  the  fourchette.  [I  have  found  a  mixture  of  eucalyptol  ( 3  i.)  and 
vaselin  (  5  iv.)  very  }3leasant  and  efficient,  but  pref er  as  a  general  lubri- 
cant a  carefully-prepared,  pure,  neutral  green  soap,  made  for  me  by 
David  Hays  &  Sons.  This  before  use  is  diluted  with  sterilized  water 
to  the  consistence  of  a  thin  jelly.]  Many  gynaecologists  advise  the 
use  of  antiseptic  injections  after  such  examination;  in  my  opinion 
they  are  not  less  demanded  beforehand.  The  finger  may  gather  and 
carry  with  it  germs  from  the  vagina  and  then  go  on  to  make  an  ero- 
sion upon  the  cervix  and  so  inoculate  the  patient.  As  a  general  rule, 
then,  vaginal  touch  should  be  practised  only  between  two  antiseptic 
injections.  To  show  the  need  of  these  precautions  it  is  well  to  re- 
member the  accidents  which  used  to  follow  simple  vaginal  touch  in 
the  days  before  antisepsis.  Vernueil,11  for  example,  reports  a  case  of 
death  from  extremely  acute  peritonitis,  the  day  after  the  examination 
by  touch  and  speculum,  of  a  woman  with  uterine  polyp;  he  cites  an- 
other of  peritouitis  which  recovered  in  a  woman  with  polyp;  and  a 
third,  of  ulcerated  polyp,  where  death  occurred  after  vaginal  touch, 
the  operation  being  postponed  but  one  day.  Howel  cites  a  similar 
case  in  his  practice,  and  one  in  Broca's,  where  death  followed  light 
cauterization  with  nitrate  of  silver.  More  recently,  in  Professor  Le 
Fort's  service,  a  woman  with  uterine  polyp  died  after  a  vaginal  exam- 
ination by  finger  and  speculum.12 

The  index  finger  is  the  most  convenient  for  vaginal  touch;  the 
thumb  should  be  kept  straight,  turned  obliquely  toward  one  or  the 
other  genito-crural  fold,  and  always  avoiding  the  median  line;  the 


METHODS    OF   GYNECOLOGICAL   EXAMINATION.  9.J 

other  fingers  are  half-Hexed  and  make  gentle  pressure  against  the 
perineum  and  inter-gluteal  space.  To  reach. the  os  the  finger  should 
follow  the  lateral  or  posterior  wall,  and  should  it  not  be  passed  in  the 
axis  of  the  canal  slight  movements  of  rotation,  from  behind  forward 
and  reversed,  will  show  its  position.  The  examiner  then  considers,  in 
regular  order,  the  direction  of  the  cervix,  its  size,  its  shape,  its  consist- 
ence, the  degree  of  its  dilatation  and  the  condition  of  the  external  os: 
Next  the  finger  explores  the  posterior  cul-de-sac,  then  the  lateral,  and 
lastly  the  anterior.  The  examination  is  not  complete,  however,  with- 
out the  aid  of  abdominal  palpation ;  that  is  to  say,  bimanual  explor- 
ation, which  will  be  treated  farther  on.  On  withdrawing  the  finger, 
the  vaginal  walls  and  perineum  are  examined  as  to  their  condition. 
There  are  times  when  the  uterus  is  very  high  up  and  difficult  to 
reach ;  in  such  a  case  both  index  and  middle  finger  must  be  deeply 
introduced,  at  the  same  time  the  pressure  against-  the  perineum  is 
increased,  if  necessary,  by  allowing  an  assistant  to  raise  the  elbow  of 
the  examining  hand.  Occasionally  cases  are  met  where  the  cervix 
cannot  be  reached  in  any  position  except  Sims'  or  the  knee-chest. '  At 
times  it  may  be  necessary  to  practise  the  vaginal  touch  with  the 
woman  erect,  as  in  certain  displacements  and  abdominal  tumors.  The 
hymen,  if  present,  may  be  an  obstacle  to  the  introduction  of  the 
index,  but  usually  this  membrane  is  elastic  enough  to  allow  the  touch, 
with  some  care,  even  upon  virgins,  without  fear  of  injuring  it.  If  this 
manoeuvre  is  very  painful,  it  is  better  to  anaesthetize  the  young  woman 
unless  the  desired  insensibility  can  be  obtained  with  cocaine.  In  such 
cases  rectal  touch  does  not  take  the  place  of  vaginal,  although  some 
authors  have  asserted  it. 

Rectal  Teuch. — It  is  necessary  to  introduce  the  finger  into  the 
rectum,  especially  to  examine  the  pouch  of  Douglas  and  the  posterior 
aspect  of  the  uterus.  Swellings  and  tumors  of  this  neighborhood  are 
not  to  be  appreciated  at  their  just  value  by  any  other  way.  It  is  often 
very  useful  in  determining  whether  the  rectum  is  full  or  empty ;  the 
lumps  of  f seces  felt  by  the  finger  in  the  vagina  might,  perhaps,  be  mis- 
taken for  pathological  products.  On  the  other  hand,  a  novice  may 
feel  the  cervix  from  the  rectum  and  make  a  similar  error.  One  must 
especially  accustom  himself  to  the  sensations  acquired  by  touch  in 
the  normal  condition.  The  combination  of  rectal  with  vaginal  touch 
is  particularly  valuable  in  examining  the  condition  of  the  recto- 
vaginal septum.13  Schroeder  strongly  advises,  in  practising  rectal 
touch,  that  the  thumb  be  passed  into  the  vagina. 


96  CLINICAL   AND   OPERATIVE   GYNECOLOGY. 

Manual  exploration  of  the  rectum,  introduced  by  Simon,14  of  Hei- 
delberg, is  to  be  employed  in  certain  exceptional  cases.  The  patient  is 
thoroughly  anaesthetized,  the  anus  is  dilated  as  for  operation  in  fissure 
of  the  part,  and  the  fingers,  gathered  into  a  cone  and  well  coated  with 
vaselin,  are  gradually  pushed  into  the  orifice  as  a  wedge;  when  the 
sphincter  has  been  passed  the  hand  rests  easily  within  the  rectal  am- 
pulla and  the  fingers  may  be  separated  for  the  examination.  I  have 
found  this  procedure  of  service  on  two  occasions  and  each  time  have 
introduced  my  hand  to  the  wrist  without  any  resulting  accident, 
erosion,  or  incontinence.  Nevertheless  I  consider  it  dangerous,  espe- 
cially if  the  surgeon's  hand  is  not  unusually  slender  and  pliable; 
there  have  been  serious  accidents  in  certain  cases.15 

Vesical  Toucli. — This  method  has  only  a  restricted  application, 
but  in  view  of  the  size  and  dilatability  of  the  female  urethra,  it  is 
generally  easy  to  carry  out  without  recourse  to  incision  as  proposed 
by  Simon.  I  have  found  no  difficulty  in  its  performance  without  pro- 
ducing any  disagreeable  consequences  after  previous  dilatation  of  the 
urethra  by  Hegar's  bougies  [or  carefully  by  the  ordinary  Palmer 
uterine  dilator].  This  method  has  been  recommended  in  cases  of  can- 
cer of  the  cervix  with  doubtful  invasion  of  the  vesical  wall  to  deter- 
mine the  mobility  of  the  mucous  membrane  uj)on  the  cervix  and  the 
presence  or  absence  of  the  complication.16 

Noeggerath's  combination  of  vesical  and  rectal  touch  renders  ex- 
cellent service  in  atresia  of  the  vagina  and  in  practising  palpation  and 
bidigital  exploration  of  the  uterus  and  appendages.17 

Among  combinations  of  methods  we  may  further  mention  vesical 
catheterism  with  vaginal  or  rectal  touch,  for,  as  Professor  Gfuyon  well 
says,  "  The  catheter  is  only  an  elongated  finger." 

Bimanual  Exploration. — I  have  described  the  vaginal  and  the 
rectal  touch  singly  for  convenience'  sake,  but  in  practice  one  seldom 
examines  without  adding  abdominal  palpation  also,  which  supple- 
ments them  admirably.  Thus  arises  the  most  valuable  method  of 
gynecological  investigation,  bimanual  exploration.  Practised  in  a 
skilful  manner  by  Puzos,  Foubert,  Levret  and  Baudelocque,  this 
manoeuvre  was  never  wholly  given  up  in  France,  but  elsewhere  it  was 
much  neglected  until  the  reintroduction  of  the  speculum.  It  is  owing 
to  the  labors  of  Schultze 18  that  it  finally  regained  its  deserved  emi- 
nent rank. 

The  glory  of  the  discovery  of  bimanual  palpation  belongs  wholly  to 
Puzos,  the  celebrated  obstetrician  of  the  eighteenth  century,  and  to  the 


METHODS    OF   GYNAECOLOGICAL   EXAMINATION.  97 

French  school.  In  his  "Traite  des  Acconch."  (Paris,  1739,  pp.  56-64), 
in  regard  to  the  insufficiency  of  the  vaginal  touch,  practised  by  him- 
self until  then,  he  says:  "There  is  another  method  of  examination 
which  furnishes,  in  a  doubtful  condition  of  a  woman,  information  as 
trustworthy  as  that  obtained  by  the  old  way  was  uncertain  and  false." 
Then  follows  a  description  of  the  method  of  axDplying  one  hand  to  the 
abdomen  and  introducing  into  the  vagina  one  or  more  fingers  of  the 
other  hand.  He  then  insists  on  precautions  necessary  for  greater  suc- 
cess in  the  operation,  such  as  doing  it  in  the  morning,  fasting,  pre- 
ceding it  with  one  or  two  enemata  to  clear  the  large  intestine,  etc. 
He  says,  furthermore:  "If  by  the  touch,  as  I  propose  it,  one  can  un- 
derstand the  normal  state  of  the  uterus,  it  is  far  easier  to  judge  of  the 
maladies  to  which  it  is  so  subject  in  circumstances  where  one  suspects 
disease."  Soon  after  Puzos  discovered  this  method  as  applicable  to 
women,  Foubert  (1736)  practised  it  upon  men,  creating  a  combination 
of  rectal  touch  and  abdominal  palpation.  He  says :  "  I  found  a  means 
at  length  which  is  simple  and  easily  informs  me  of  the  degree  of  ful- 
ness of  the  bladder;  with  the  finger  which  I  have  introduced  into  the 
rectum  and  the  hand  which  I  have  applied  to  the  abdomen,  I  make 
many  alternating  movements,  which  determine  exactly  how  full  the 
organ  is  through  the  rectal  membranes  ("Mem.  d.  Acad.  Roy.  d. 
Chirurg.,"  t.  I.,  p.  301,  1743).  After  Puzos  the  method  became  general 
in  France,  and  Levret,  especially,  mentions  it  often  in  his  works  on 
obstetrics  and  diseases  of  women.  Baudelocque  says :  "  Touch  means 
not  only  the  finger  in  the  vagina,  but  also  the  hand  upon  the  abdo- 
men," and  advises :  "  relax  the  abdominal  muscles,  evacuate  the  urine 
and  fseces,  etc.,  displace  the  small  intestine  right  and  left  with  the 
hand  on  the  abdomen,  pressing  toward  the  uterus  ("  L' Art  d.  Accouch.," 
t.  I.,  p.  125,  1781).  He  also  states  {ibid.,  p.  325)  that  in  extra-uterine 
pregnancy  it  is  by  this  means  that  the  position  of  the  child  can  be 
discovered,  whether  in  the  tube  or  the  abdominal  cavity.  The  method 
is  further  described  in  his  "Art  des  Accouchements,"  arranged  in  ques- 
tion-and-answer  form,  which  was  translated  into  German  ("Anfang  d. 
Geburt.,"  Colmar,  1807,  p.  84).  In  France  this  exploratory  method  has 
never  been  abandoned,  but  has  been  in  skilful  and  constant  use.  Th. 
Giraud,  in  a  thesis  on  acute  ovarian  phlegmasia,  says :  "  Touch  by  ab- 
domen and  vagina  is  a  precious  possession,  which  should  be  insisted 
upon  as  the  regulator,  the  mariner's  compass,  of  diagnosis  "  (Paris, 
1831,  ISTo.  169,  p.  13). 

Yelpeau,  after  describing  the  combined  method,  says  that  nothing 

7 


98 


CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 


can  escape  the  two  hands  as  they  meet.  "  It  is  seldom  that  a  simple 
engorgement  of  ovaries  or  tubes,  of  the  uterine  adnexa  in  general  or 
of  the  lymph  ganglia,  or  the  presence  of  a  small  vesical  calculus,  is  over- 
looked "  ("  Trait.  Compl.  d.  l'Art  d.  Accouch.,"  1885, 2d  edit.,  1. 1.,  p.  192). 
Much  later  ("  Discuss.  Acad.,  Malad.  d.  1'Uter.,"  1854,  p.  83)  he  says  : 
"  One  can  thus  lay  hold  of  the  uterus  between  the  two  hands,  estimate 
its  density,  direction,  shape,  all  its  physical  characteristics,  in  one  word, 
obtain  the  same  clearness  of  idea  as  if  it  were  upon  the  table  and  sim- 
ply wrapped  in  cloth."    He  mentions  also  that  the  number  of  women 


Fig.  69.— Bimanual  Exploration. 


whom  you  cannot  thus  examine  is  very  small:  "  I  have  collected  sta- 
tistics upon  this  point,"  he  declares,  "  lasting  over  considerable  time, 
and  out  of  four  hundred  I  have  not  found  more  than  one  hundred 
refractory,  and  these  not  absolutely  so."  And  that  no  one  may  sup- 
pose the  method  but  recently  invented — "  I  have  proved  its  exactness 
every  day  at  the  hospital  for  twenty-five  years,  demonstrating  it  at 
the  bedside  to  any  one  who  desired  it." 

It  thus  becomes  plain  that  Hegar  is  wrong  in  claiming  the  honor 
of  its  discovery  for  von  Schultze,  Hoist,  and  Yeit.  The  subject  has 
been  well  treated  by  L.  Guernes  ("De  l'Hemato-salping.,"  These  de 
Paris,  1888,  No.  178). 


METHODS    OF   GYNECOLOGICAL   EXAMINATION.  99 

For  the  employment  of  the  method  the  patient  is  placed  in  simple 
dorsal  decubitus,  or,  if  that  position  offers  any  difficulty,  as  for  lithot- 
omy; while  the  index  of  the  right  hand  practises  the  touch,  as  de- 
scribed, the  left  hand  is  laid  above  the  pubis,  and  the  fingers  sunk 
inward  with  gentle,  even  pressure,  thus  driving  the  pelvic  contents 
toward  the  vaginal  finger.  To  make  clear  the  exact  position  of  the 
uterus,  this  procedure  is  carried  out  in  the  hypogastric  region,  then  in 
the  inguinal,  and  lastly  the  lumbar  should  be  examined,  the  vaginal 
finger  exploring  the  depths  of  the  culs-de-sac  toward  the  other  hand; 


Fig.  70.— Bimanual  Exploration.    Sectional  view  (Davenport). 

thus  the  bases  of  the  broad  ligaments  and  the  uterine  adnexa  are 
easily  examined  for  abnormal  enlargements.  At  the  same  time  account 
should  be  taken  of  the  sensitiveness  of  the  parts ;  in  the  healthy  con- 
dition, pressure  over  the  adnexa,  as  also  elevation  and  tossing  (balotte- 
ment)  of  the  uterus,  are  free  from  pain. 

Bimanual  palpation  should  then  be  made  by  rectum  and  abdomen 
(Hoist) ;  it  is  particularly  advisable  in  disease  of  the  adnexa. 

By  the  combined  method  one  can  palpate  the  ovaries,  with  special 
facility  if  the  patient  is  anaesthetized,  but  even  without  such  aid. 
It  is  well,  as  Hegar  advises,  to  have  the  uterus  gently  pulled  down 
by  an  assistant,  the  cervix  being  fixed  with  a   (tenaculum)  forceps 


100 


CLINICAL   AXD    OPERATIVE   GYNAECOLOGY. 


while  the  surgeon  palpates  the  abdomen  and  passes  the  index  of  the 
other  hand  by  turns  into  vagina  or  rectum ;  the  ovary  is  felt  to  glide 
between  the  fingers  like  a  small  testicle.  The  left  ovary  is  more  easily 
reached  than  the  right,  which  Olshausen  attributes  to  its  position  in 
front  of  the  rectum.  With  obese  patients  this  method  of  examina- 
tion has  many  difficulties.  Instead  of  adopting  Noeggerath's  vesico- 
rectal method,  I  think  it  better  to  have  recourse  to  the  plan  advised 
by  Ulmann 19  (a  pupil  of  Albert,  Vienna)  in  difficult  cases  where  ovarian 
palpation  seems  indispensable ;  the  bladder  being  emptied,  there  is 


Fig.  71. — Bimanual  Exploration  in  Retroversion  CDavenport). 

passed  into  the  rectum  a  balloon  filled  with  200-250  gm.  of  water. 
Now  bimanual  palpation  reveals  the  uterus  and  its  appendages 
strongly  elevated  and  held  in  that  position  upon  a  resistant  body, 
which  makes  them  very  accessible. 

Examination  by  Speculum. — After  Recamier  had  reinvented  the 
speculum,  this  valuable  instrument  led  to  the  neglect  of  all  other  ex- 
ploring methods;  from  this  point  of  view,  one  may  assert  that  the 
great  service  it  has  rendered  to  gynaecology  has  been  equalled  by 
the  temporary  evil  it  has  caused. 

The  form  of  the  instrument  has  undergone  endless  changes;  but  of 
these,  however  ingenious,  only  a  small  number  are  absolutely  neces- 
sary. 


METHODS   OF   GYNECOLOGICAL   EXAMINATION.  101 

There  are  three  chief  types,  the  cylindrical,  the  bivalve  or  the  tri- 
valve,  and  the  univalve. 

The  Cylindrical  Speculum.— This  form  is  particularly  suited  to 
topical  applications;  made  of  wood  or  ivory  it  protects  the  vaginal 
walls  from  heat  during  the  use  of  the  actual  cautery ;  made  of  sil- 
vered glass  and  covered  with  hard-rubber  [or  better  of  white  cellu- 
loid] it  cannot  be  used  for  that  purpose,  but  is  valuable  on  account  of 
the  clear  view  it  gives  and  the  ease  with  which  it  can  be  intro- 
duced, both  for  superficial  examinations  and  for  the  different  dress- 
ings and  applications  which  are  required  for  the  cervix.  These 
specula  should  not  be  too  long  and  the  end  should  be  bevelled  to 


~Fig.  72. — Ferguson's  Cylindrical  Speculum,  to  which  is  fitted  a  rubber  funnel  for  dressings  and  fluids. 

correspond  to  the  greater  depth  of  the  posterior  vaginal  cul-de-sac. 
It  is  necessary  to  have  at  least  three  different  sizes. 

Before  introducing  the  speculum  it  is  well  to  dip  it  in  warm  water 
so  that  its  polished  surfaces  may  not  be  dimmed  by  the  vaginal  mois- 
ture. It  is  then  coated  with  vaselin  and  presented  obliquely  to  the 
vaginal  orifice,  whose  lips  are  separated  by  the  fingers  of  the  other 
hand.  The  point  of  its  bevelled  end  is  then  pressed  backward  against 
the  perineum,  and  glides  over  the  groove  of  the  fourchette,  avoiding 
friction  against  the  urethra  and  anterior  vaginal  wall  as  much  as  pos- 
sible. When  the  vaginal  orifice  has  been  passed,  the  instrument  is 
tilted  so  that  its  axis  corresponds  with  the  direction  of  the  cervix, 
previously  ascertained  by  the  finger,  is  pushed  up  gently,  aided  by 


102  CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 

the  sight,  to  embrace  the  external  os,  guarding  against  the  tendency 
to  search  for  that  structure  too  far  behind  and  too  deeply.  [In  cer- 
tain cases  where  the  vagina  is  very  voluminous,  or  the  cervix  in  an 
unusual  position,  it  may  be  difficult  to  engage  the  cervix  in  the  lumen 
of  the  speculum.  In  these  instances  the  sound  may  be  iirst  intro- 
duced and  the  speculum  passed  over  it  as  a  guide,  or  a  tenaculum  may 
be  used  for  the  same  purpose.] 

Multivalve  Specula. — It  is  needless  to  describe  the  three-valved 
instrument  of  Segalas,  or  the  four-valved  model  of  Charriere,  in  spite 
of  their  interesting  history ;  those  of  more  recent  invention  appear  to- 
me but  little  better.     [The  Nott  speculum  is  the  best  of  this  class.] 

Bivalved  specula  are  the  most  useful  to  the  general  practitioner. 


Fig.  73.  —Brewer's  Speculum. 

Cusco's  or  Brewer's  speculum,  the  so-called  "  duck-bill,"  is  an  ele- 
gant and  simple  instrument,  especially  adapted  to  use  in  examinations ; 
it  has  the  advantage  of  allowing  insrjection  of,  first,  the  os,  then,  by 
gradual  withdrawal,  of  the  culs-de-sac  and  vaginal  walls.  Its  small 
size  and  readiness  of  introduction  make  it  valuable,  and  it  may  be 
kept  aseptic  by  placing  it  a  few  minutes  in  boiling  water  or  strong 
carbolic-acid  solution.  The  introduction  of  this  instrument  is  accom- 
plished according  to  the  rules  laid  down  for  the  use  of  the  cylin- 
drical. I  would  merely  remind  students  that  the  axis  of  the  vulva  is 
perpendicular  to  that  of  the  vagina,  and  that  while  the  end  of  the 
speculum  should  be  turned  obliquely,  at  an  angle  of  45°  to  open 
the  vulvar  orifice,  it  should  be  restored  to  the  horizontal  position  as 
soon  as  it  has  passed  in.  The  blades  must  not  be  separated  until  the 
instrument  is  wholly  within  the  vagina,  in  order  that  the  vulva  may 
not  be  unduly  distended.   In  all  of  the  bivalve  specula,  it  is  necessary 


METHODS    OF   GYNAECOLOGICAL   EXAMINATION. 


103 


to  have  a  groove  or  slit  in  the  upper  blade  to  avoid  pressure  upon 
the  sensitive  parts  about  the  urethra  and  to  render  the  introduction 
of  instruments  (sound)  less  difficult. 

One  must  not  forget  that  the  introitus  is  the  narrowest  part  of  the 
genital  canal,  and  that  just  within  it  the  vagina  forms  a  kind  of 
pouch  comparable  to  the  rectal  ampulla ;  the  diverging  of  the  blades 
in  the  bivalve  speculum  is  therefore  seen  to  be  essential. 

Univalve  Specula. — These'  instruments  are  chiefly  intended  for 


Fig.  74.— Simon's  Speculum. 


Fig.  75. — Vaginal  Retractor. 


use  in  operation.  With  only  one  it  is  easy  to  reach  the  vaginal  wall 
opposite  the  instrument,  and  so  with  the  patient  in  the  Sims  or  genu- 
pectoral  position,  one  can  easily  reach  the  cervix.  With  two  single 
blades,  employed  at  the  same  time,  we  have  the  best  possible  method 
of  examining  vagina  and  cervix,  but  it  has  the  inconvenience  of  re- 
quiring assistance.  Long  before  Sims  made  the  use  of  the  univalve 
speculum  common,  such  instruments  had  been  employed  by  certain 
skilled  practitioners.  Eecamier,  Piorry,  Jobert  de  Lamballe,  in 
France,  made  use  of  half-cylinders,  sometimes  of  small  metal  splints 
mounted  on  handles. 

The  latter  surgeon  owed  his  success  with  vesico- vaginal  fistula  as 


104 


CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 


muck  to  his  superior  instruments  as  to  the  brilliance  of  his  concep- 
tions. 

Sims'  speculum  is  to  be  employed  in  the  semi-prone  position  which 
bears  his  name.  In  his  instrument  two  blades  are  joined  end  to  end 
to  lessen  the  number  of  single  instruments.  In  the  seim/prone  posi- 
tion this  arrangement  presents  no  difficulty,  but  it  is  almost  impossi- 
ble to  use  the  instrument  in  the  lithotomy  position,  ordinarily  adopted 
in  France.  The  blades  are  of  metal  and  their  surface  is  bright  to 
reflect  the  light.  For  my  own  part,  I  prefer  Simon's  hollow  blades. 
They  are  mounted  on  a  handle  and  have  a  strongly-marked  sweep. 
They  come  in  sets  and  are  made  concave  for  depression  of  the  poste- 
rior vaginal  wall  (this  shape  augments  the  amount  of  light),  and 


Fig.  76.— Sims^  Speculum.    One  blade  is  shown  with  the  flange  devised  by  Mund6  for  supporting 

the  upper  buttock. 


flat  for  the  anterior  wall.  Moreover,  in  the  course  of  an  operation  one 
can  employ  one  or  more  retractors,  which  are  narrow  blades  mounted 
on  Handles  long  enough  to  keep  them  out  of  the  surgeon's  way. 

One  variety  of  Simon's  blades  is  very  short,  reduced  almost  to  its 
anterior  portion  and  widened  at  that  place  to  increase  the  amount  of 
reflecting  surface ;  this  is  particularly  useful  for .  operations  on  the 
cervix,  where  it  is  to  be  drawn  down  to  the  entrance  of  the  vagina. 

[While  the  comfortable  and  efficient  use  of  the  Sims  speculum  usu- 
ally necessitates  the  presence  and  aid  of  a  nurse,  there  is  no  other 
'means  by  which  the  cervix  and  anterior  vaginal  wall  can  be  so  per- 
fectly exposed  without  interfering  with  the  natural  relations  or 
mobility  of  the  parts.  In  manipulations  requiring  the  use  of  one 
hand  only,  such  as  applications  or  tamponade,  the  operator  can,  if 
necessary,  hold  the  instrument  with  his  left  hand,  the  flanged  mod- 


METHODS   OF   GYNECOLOGICAL    EXAMINATION. 


105 


ification  of    Munde  being  employed  so  as  to  support   the  upper 
buttock. 

There  are  many  modified  forms  of  the  Sims  speculum,  varying  in 
curve  or  breadth,  but  none  are  better  than  those  here  shown  which 
can  be  procured  in  several  different  sizes.    Many  attempts  have  been 


b 
Fig.  77.— a,  Sims'1  depressor  for  the  anterior  vaginal  wall;  b,  tenaculum  with  stiff  shank. 

made  to  devise  a  perfect  self-retaining  speculum  of  this  class,  but 
none  have  proven  entirely  satisfactory.  That  devised  by  Cleveland 
is  the  best  and  is  very  efficient  in  most  cases.  It  can  also  be 
used  with  the  patient  in  the  lithotomy  position,  being  held  in  place 
by  a  piece  of  rubber  tubing  laid  under  the  patient's  hips,  and  retained 
by  her  weight.  I  have  often  done  small  operations  in  this  way  very 
satisfactorily  and  with  no  assistant  but  the  ansesthetizer.     There  are 


Fig.  78.— Cleveland's  Self-retaining  Speculum. 

two  instruments,  the  depressor  and  tenaculum,  which  are  indispensa- 
ble in  using  the  Sims  ;  the  first  to  press  forward  the  anterior  vaginal 
wall  and  to  bring  the  cervix  forward  into  the  axis  of  the  speculum, 
and  the  latter  to  steady  it  or  draw  it  slightly  downward  or  forward. 
To  insert  the  speculum,  the  patient  being  in  the  Sims  .position  already 
described,  the  warmed  and  lubricated  instrument  is  taken  firmly  by 
the  external  blade  in  the  left  hand,  and  the  point  of  the  blade  to  be 


106 


CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 


used  passed  into  the  vaginal  orifice  with  the  concavity  directed  up- 
ward (or  downward),  the  upper  buttock  and  labium  being  lifted  out  of 
the  way  by  the  right  hand  or  by  the  nurse.  As  soon  as  the  point  of 
the  blade  is  fairly  in  the  vagina,  the  concavity  is  turned  forward  and 
the  point  backward  when  it  glides  along  the  posterior  vaginal  wall 
until  completely  inserted,  when  on  retracting  the  perineum  backward 
and  slightly  upward  the  cervix  will  be  exj)osed.  A  slight  upward 
tilt  to  the  outer  end  of  the  speculum  allows  a  better  light.  The  cer- 
vix being  exposed,  the  speculum  is  handed  to  the  nurse  who,  standing 
at  the  patient's  sacrum,  grasps  the  blade  firmly  with  the  full  hand  and 
continues  the  traction  in  the  same  direction,  her  arm  resting  against 
her  side.     This  holding  of  the  instrument  is  at  first  very  irksome  and 


Fig.  79. — Belt  for  Use  with  Cleveland's  Self-retaining  Speculum. 


difficult,  but  it  is  an  accomplishment  soon  acquired  after  a  little  prac- 
tice. The  traction  must  be  even  and  steady  so  as  not  to  cause  pain 
to  the  patient  and  must  be  made  so  as  not  to  tip  the  point  of  the 
blade  too  far  forward  or  backward.  If  the  posterior  wall  is  closely 
followed  in  inserting  the  blade  and  it  is  passed  behind  the  cervix,  the 
latter  will  come  into  view  easily,  and  it  is  not  necessary  to  pass  in  the 
blade  on  the  finger  as  was  formerly  taught.  There  is  sometimes  diffi- 
culty in  exposing  the  cervix  where  the  vagina  is  long  and  voluminous, 
and  in  these  instances  it  is  very  necessary  to  have  the  patient  in  good 
position  and  all  clothing  loose.  Very  rarely  it  may  be  necessary  to 
put  the  patient  in  the  knee  chest  position.] 

Uterine  Sounds. — Levret  appears  to  have  been  the  first  who  ex- 
plored the  uterine  cavity  by  introducing  an  instrument,  but  it  was 


METHODS    OF    GYNAECOLOGICAL    EXAMINATION.  107 

only  after  the  writings  of  Hnguier  in  France,  Simpson  in  England,  and 
Kiwisch  in  Germany,  that  its  use  became  general.  As  it  first  became 
known  it  was  much  abused,  and  Scanzoni  complained  with  reason 
against  such  excess.  The  forms  of  the  hysterometer  have  been  mul- 
tiplied, without  real  advantage;  the  simplest  is  the  best.  It  is 
a  single  graduated  metallic  stem,  ending  in  a  small  button  above,  and 
below  in  a  broad  spatula-shaped  handle,  which  facilitates  the  opera- 
tion of  holding  and  guiding  it.  The  instrument  should  have  some 
rigidity,  and  yet  be  flexible  enough  to  take  and  preserve  the  different 
curvatures  which  it  may  be  necessary  to  give  it ;  silver  and  pure  cop- 
per are  the  best  materials  for  this  purpose;  the  inflexible  hysterom- 
eters  of  German  silver  should  be  rejected.  The  little  slides  which 
are  made  to  be  pushed  along  till  flush  with  the  cervix,  and  so  mark 
the  depth  of  the  uterus,  should  also  be  proscribed;  it  is  sufficient  for 
this  purpose  to  seize  the  sound  with  dressing  forceps  at  the  desired 
point  [or  to  jDlace  the  finger  against  the  sound  at  the  os  as  it  is  with- 
drawn] and  read  the  degree  marked  on  the  scale.     The  sound  should 


GzoTIEMANNScCo. 


Fig.  80.— Uterine  Sound, 

never  be  used  without  having-  previously  ascertained  the  position, 
shape,  and  size  of  the  uterus  [and  the  absence  of  peri-uterine  inflam- 
mations or  the  possibility  of  pregnancy]  by  means  of  bimanual  palpa- 
tion; otherwise  one  gropes  in  the  dark  and  may  produce  serious  in- 
juries. Jt  is  enough  to  bend  the  tip  of  the  instrument  in  the  desired 
curve  and  to  carry  the  handle  in  the  opposite  direction,  to  introduce 
it  with  ease,  even  in  flexions  of  the  uterus. 

Flexible  sounds  have  been  invented,  furnished  or  not  with  dials, 
which  seem  to  me  better  than  simple  rubber  bougies,  when  a 
rigid  sound  will  not  enter  on  account  of  the  sinuous  curves  of  the 
cavity.20  [These  are  practically  never  required.]  The  best  position 
for  sounding  is  the  dorso-sacral.  It  can  be  done  without  the  aid  of  a 
speculum,  by  slipping  the  instrument  along  the  palmar  aspect  of  the 
index  held  at  the  orifice  of  the  cervix.  The  pressure  applied  must  be 
very  gentle,  and  one  must  bear  in  mind  that  there  is  almost  always  a 
feeling  of  constriction  at  the  upper  part  of  the  cervix.  The  finger 
applied  to  the  stem,  at  the  margin  of  the  external  os,  shows  how 
deeply  it  has  penetrated.     It  is  probably  better  to  employ  the  specu- 


108  CLINICAL   AND    OPERATIVE    GYNAECOLOGY. 

lum  tliat  there  may  be  no  difficulty  in  the  procedure  and  because  of 
the  aid  to  diagnosis;  detraction  and  fixation  of  the  cervix  should  be 
accomplished  by  a  pair  of  hooked  forceps.  This  is  at  times  the  only 
way  of  reaching  the  cervix  if  it  is  displaced  into  one  or  the  other  of 
the  vaginal  culs-de-sac,  as  in  malpositions  of  the  uterus.  I  have  found 
gentle  traction  upon  the  cervix  of  value,  from  its  effect  of  straighten- 
ing the  uterine  canal. 

[It  must  be  remembered  that  the  passage  of  the  sound  is  to  be 
accomplished  with  the  utmost  gentleness,  the  instrument  being  held 
delicately  between  the  thumb  and  forefinger,  and  that  skill  must  take 
the  place  of  force.  The  conditions  under  which  it  may  be  employed 
have  been  mentioned  and  necessitate  a  practical  knowledge  of  bi- 
manual palpation.  The  physician  will  find  that  the  more  skilful  he 
"becomes  in  pelvic  examination,  the  less  often  he  will  need  the  infor- 
mation given  by  the  sound.  I  prefer  to  use  the  instrument  with  the 
patient  in  the  dorsal  position  and  without  the  speculum,  as  much  more 
information  as  to  the  mobility  and  position  can  be  obtained.  The 
beginner  usually  finds  difficulty  in  passing  the  internal  os  when  the 
uterus  is  in  a  normal  position  or  anteflexed.  This  obstruction  is 
usually  overcome  by  markedly  depressing  the  handle  of  the  sound 
when  its  tip  reaches  this  point.  In  a  few  cases  this  manoeuvre  may 
fail  and  it  may  be  necessary  to  put  the  patient  on  the  side  and  pass  it 
through  the  Sims  speculum,  steadying  and  straightening  the  cervix 
by  means  of  a  tenaculum.] 

The  mOst  vigorous  antisepsis  is  indispensable  wiien  passing  the 
uterine  sound,  the  instrument  being  disinfected  as  already  described, 
and  after  each  examination  heated  in  the  flame  of  an  alcohol  lamp. 
A  vaginal  injection  and  a  thorough  antiseptic  cleansing  of  the  cervix, 
by  means  of  a  stick  wrapped  with  absorbent  cotton,  are  necessary 
preliminaries.  The  researches  of  Winter21  have  demonstrated  that 
in  the  majority  of  cases  the  cervix  contains  pathogenic  germs,  dor- 
mant and  inactive,  possessed  of  a  very  slight  virulence  as  inoculation 
proves;  but  these  germs  have  never  been  found  by  him  within 
the  cavity  of  the  uterus  unless  the  sound  had  previously  been 
used.  The  sound,  therefore,  can  without  any  doubt  transport  these 
germs  to  the  upper  portions  of  the  genital  tract,  where  normally 
they  are  not  present,  and  this  is  the  cause  of  the  accidents — metritis, 
salpingitis,  and  perimetritis — which  one  may  observe  after  the  use  of 
a  proper  sound  which  has  passed  through  a  cervical  cavity  not  previ- 
ously cleansed. 


METHODS    OF   GYNAECOLOGICAL   EXAMINATION.  109 

I  would  consequently  recommend  with  emphasis  that  the  young- 
doctor  should  never  use  the  uterine  sound  without  being  assured  of 
two  chief  points:  1st.  The  fact  that  the  uterus  is  empty,  ascertained 
by  careful  questions  and  bimanual  palpation;  in  the  case  of  any 
doubt,  indicated  by  delay  in  menstruation  for  several  days,  the  pro- 
cedure must  be  given  up;  for  numerous  abortions  were  produced  dur- 
ing the  time  when  the  sound  was  used  with  too  great  frequency.  2d. 
The  strict  asepsis  of  the  instrument.  The  notches  marking  its  grad- 
uation are  difficult  to  clean  thoroughly,  and  it  would  be  better  to  use 
instruments  which  are  not  so  marked  at  the  price  of  making  measure- 
ments a  little  less  conveniently. 

The  sound  must  be  held  in  the  flame,  after  having  been  washed 
with  carbolic-acid  solution,  immediately  before  its  introduction.  I 
have  known  several  cases  of  metritis  and  salpingitis  after  the  use  of 
the  sound  in  the  hands  of  well-known  physicians,  which  are  to  be 
attributed. to  the  lack  of  minute  antiseptic  precautions. 

The  uterine  sound  affords  us  an  exact  idea  of  the  permeability  of 
the  cervical  canal,  of  the  two  diameters  of  the  uterus,  longitudinal  and 
transverse,  and  also  of  the  organ's  general  direction.  In  the  normal 
state  the  sound  passes  without  difficulty,  except  for  a  slight  resist- 
ance at  the  level  of  the  isthmus,  to  the  depth  of  five  or  six  centimetres 
in  nulliparae,  and  six  or  seven  (two  and  one-half  inches)  in  those  who 
have  borne  children. 

The  extent  of  lateral  movement  which  it  can  make  is  very  limited ; 
it  is,  so  to  say,  immobilized  between  the  anterior  and  the  posterior 
wall.  If,  however,  the  point  of  the  instrument  is  freely  movable  and 
can  be  turned  in  different  directions,  it  is  because  the  antero-posterior 
and  transverse  diameters  are  increased  and  the  cavity  is  of  unusual  size. 

Is  it  possible  to  pass  the  sound  into  the  Fallopian  tubes  ?  This  is 
the  explanation  of  some  authors  in  those  cases  where  the  instrument 
penetrates  deeply  into  the  abdomen  and  can  be  detected  through  its 
wall.  That  this  may  occur  there  must  be  a  combination  of  very  un- 
usual circumstances :  a  latero  version  of  the  uterus  which  brings  the 
orifice  of  the  tube  into  the  long  axis  of  the  cervix  and  an  exceptional 
wideness  of  its  opening.  This  condition  actually  existed  in  a  case 
observed  by  Bischoff,22  and  was  verified  after  death  following  ovario- 
tomy. But  in  almost  every  one  of  the  published  cases  of  pretended 
sounding  of  the  tubes,  it  is  far  more  likely  that  there  was  a  perfora- 
tion of  the  uterus — a  condition  which  is  easily  produced  without 
exaggerated  efforts  when  the  uterus  is  softened  and  thinned  from 


110  CLINICAL   AND   OPERATIVE   GYNECOLOGY. 

pregnancy  or  recent  abortion,  or  when  it  is  displaced;  the  benign 
character  of  such  wounds  has  surprised  most  of  those  who  have  wit- 
nessed their  production  and  has  induced  them  to  seek  an  explanation 
which  appears  more  plausible.  This  is  without  doubt  the  significance 
which  must  be  given  to  two  cases  recently  reported  by  Gonner 23  of 
Basel.  Finally  we  may  note  the  possibility  of  establishing  permanent 
false  passages  and  the  introduction  of  the  sound  by  the  same-  route 
into  the  abdominal  cavity.  But  these  are,  in  truth,  but  pathological 
curiosities,  with  which  we  have  little  to  do.24 

Fixation  and  Downward  Traction  of  tlie  Uterus. — This  proced- 
ure should  be  classed  among  exploratory  methods,  not  that  it  is  em- 
ployed by  itself,  but  because  it  renders  immense  service,  associated 
with  other  means,  in  facilitating  examination. 

Hegar 25  has  shown  that  it  is  possible  by  this  method  to  examine 
the  entire  posterior  aspect  of  the  uterus,  and  even  to  reach  beyond 
the  fundus  by  rectal  touch,  simply  by  seizing  the  cervix  with  a  pair  of 
forceps  and  gently  drawing  it  downward.  I  have  already  indicated 
all  the  advantage  procured  by  the  passage  of  the  sound  with  fixation 
of  the  cervix  and  without  infra-traction.  We  will  see  also  that  direct 
exploration  of  the  uterine  cavity  demands  the  same  auxiliary. 

Many  practitioners  dread  to  employ  this  method  of  drawing  down 
the  uterus.  Before  antiseptics  many  accidents  were  attributed  to  it 
which  were  due  to  infection.  The  profession  was  urged  to  contend 
against  such  fatal  practices.  But  nothing  is  less  dangerous  than 
infra-traction  of  the  uterus  when  antiseptic  precautions  are  observed; 
even  when  the  procedure  is  carried  out  with  force,  as  in  bringing  the 
external  os  to  the  vulva  in  certain  operations,  there  is  no  danger  with 
strict  antisepsis.  For  my  part  I  daily  practise  the  one  or  the  other 
method  in  my  service  and  have  never  met  with  an  accident  which 
could  be  attributed  to  it.  It  is  only  necessary  to  remember  that  there 
is  danger  as  long  as  there  is  the  least  sign  of  acute  or  subacute  peri- 
metritis. 

It  seems  advisable  to  me  to  establish  a  distinction  between  fixation 
and  downward  traction  (abaissement).  The  first  denotes  merely 
holding  the  uterus  steady  with  as  little  traction  as  possible  upon  its 
ligaments;  the  other  actually  pulls  the  organ  downward,  with  a  per- 
ceptible effort,  below  its  normal  level.  Now,  in  examining  it  is  rarely 
necessary  to  go  beyond  simple  fixation,  and  if  the  organ  is  at  all 
drawn  downward,  the  degree  of  such  traction  is  very  moderate. 

The  method  employed  is  very  simple.     The  patient  being  placed 


.METHODS    OF    GYNECOLOGICAL    EXAMINATION. 


Ill 


in  the  clorso-sacral  position,  the  operator  grasps  the  anterior  lip  of  the 
cervix,  guided  to  it  by  his  index  linger  or  through  a  speculum.  A 
hooked  forceps  (which  is  merely  an  American  bullet  extractor)  is  the 
best  instrument  for  the  purpose  (Fig.  81);  it  makes  only  two  tri- 
lling rmnctures,  which  cause  no  discomfort  and 
bleed  but  little.  It  is  only  when  the  force  em- 
ployed needs  to  be  great,  or  the  position  main- 
tained a  long  time,  that  Museux's  forceps  are 
required ;  we  must  then  take  care  that  they  are 
constructed  according  to  the  model  I  have 
recommended,  where  the  blades  meet  exactly 
without  the  over  riding  which  is  found  in  the 
form  most  commonly  used.  With  this  small 
matter  correct,  the  wound  made  is  very  slight, 
and  the  surgeon  need  run  no  risk  of  injury  to 
his  finger  as  he  passes  it  over  the  part  seized. 

Artificial  Dilatation  of  the  Uterus,  and 
Intra-uterine  Touch. — There  are  certain  rare  ca- 
ses where  it  is  necessary  to  explore  the  uterine 
cavity  with  the  finger,  either  to  confirm  a  diag- 
nosis or  as  a  preliminary  to  operation.  This  bold 
plan  originated  with  Simpson;  to  accomplish  it 
several  methods  have  been  proposed.  Before 
discussing  them  it  is  necessary  to  establish  a 
distinction ;  the  cervix  presents  a  narrow  canal, 
not  a  simple  orifice,  which  has  an  upper,  supra- 
vaginal, and  a  lower,  or  external  mouth.  The 
points  requiring  especial  consideration  are  the 
condition  of  the  internal  os  and  of  that  part  of 
the  cervical  canal  which  lies  above  the  vagina. 
In  certain  cases  the  patency  and  greater  or  less 
degree  of  softening  of  the  internal  os  present  no 
obstacle  to  exploration,  except  below  at  the  os 
externum ;  for  instance,  in  certain  intra-uterine 
fibromata  and  polypi,  just  after  abortion,  etc.  Such  cases  are  essen- 
tially different  from  those  where  the  whole  extent  of  the  canal  is  rigid, 
and  the  same  measures  will  not  produce  equivalent  effects  in  the  one 
class  as  in  the  other.     Let  us  pass  the  principal  procedures  in  review. 

The  principal  methods  of   dilatation  may  be  divided  into  two 
classes : 


Fig.  81.— Fixation  Forceps. 


112  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

1.  Bloodless  methods,  comprising:  A.  Gentle  dilatation  by  tents ; 
B.  Divulsion;  C.  Immediate  progressive  dilatation. 

2.  Those  accompanied  with  bleeding,  consisting  of  two  important 
operations  of  diverse  character,  viz.:  A.  Opening  of  the  external  os  by 
incision ;  B.  Entire  bilateral  division  of  the  cervix. 

No  one  of  these  procedures  should  be  adopted  in  practice  unless 
absolutely  necessary,  and  every  dilation  of  the  uterus  should  be  re- 
garded as  dangerous,  particularly  if  there  is  the  least  reason  to  suspect 
recent  inflammation  about  the  uterus  or  its  appendages. 

Bloodless  Methods. — A.  Gentle  dilatation  by  means  of  absorbent 
expansive  materials  is  accomplished  by  introducing  into  the  cervical 
canal  cylinders  of  different  material,  among  which  prepared  sponge, 
laminaria,  tupelo,  slippery  elm,  decalcified  ivory,  and  gentian  root 
are  advocated.36  I  will  not  stop  to  discuss  the  relative  merits  of  these 
various  tents ;  the  matter  seems  to  me  decided  in  favor  of  laminaria, 
and  although  I  do  not  wholly  reject  prepared  sponge,  rendered  asep- 
tic, I  still  believe  that  it  has  only  a  limited  application.  Laminaria, 
used  in  fagots,  that  is,  several  tents  at  once,  if  necessary,  suffices  for 
nearly  all  our  needs.  This  excellent  therapeutic  agent  was  intro- 
duced to  surgeons  by  Sloan.27 

After  thorough  disinfection  by  laying  them  in  iodoform-ether, 
tents  are  employed  in  the  following  manner:  The  vagina  is  carefully 
irrigated;  the  patient  then  being  put  in  the  dorso-sacral  position, 
the  cervix  is  exposed  by  the  bivalve  speculum  or  two  of  Simon's 
blades ;  it  is  then  advisable  to  grasp  the  anterior  lip  of  the  cervix 
with  a  tenaculum  forceps  and  thus  hold  it  firm  during  the  introduc- 
tion of  the  tent;  the  position  of  the  uterus  must  have  been  ascer- 
tained beforehand  by  the  use  of  bimanual  palpation  and  the  sound. 
The  tent  should  be  slightly  curved  to  adapt  it  to  the  natural  curve 
of  the  canal  which  is  to  receive  it ;  then,  wxell  covered  with  vaselin,  it 
is  grasped  by  a  forceps  and  gently  introduced.  The  end,  to  which  a 
small  thread  is  attached,  must  be  left  outside  the  cervix.  Two  or 
three  tents  may  thus  be  inserted  within  the  canal  if  the  introduction 
of  one  of  sufficient  size  is  too  difficult,  for  violence  must  never  be  em- 
ployed. The  fixation  forceps  being  removed,  a  tampon  of  iodoform 
gauze  is  placed  over  the  cervix  and  then  the  speculum  is  withdrawn. 

About  ten  hours  are  required  for  the  laminaria  tent  to  become 
thoroughly  dilated;  then  it  is  removed  by  gentle  traction  upon  the 
thread  passed  through  its  lower  end.  Sometimes,  however,  there  is 
some  difficulty,  as  the  tent  may  have  assumed  an  hour-glass  shape, 


METHODS    OF    GYNECOLOGICAL    EXAMINATION. 


113 


from  constriction  at  the  internal  os.  Then  the  extremity  must  be 
seized  with  a  forceps,  and  withdrawn  by  combined  traction  and  rota- 
tion, while  the  linger  offers  a  point  of  support  at  the  external  os. 

Despite  all  antiseptic  precautions,  we  must  not  regard  dilatation  by 
tents  as  an  inoffensive  operation;  for  one  sometimes  encounters  symp- 
toms of  acute  metritis  after  their  use,  with  severe  pain  and  marked 
febrile  movement.  They  should,  therefore,  be  employed  with  more, 
moderation  than  is  usually  advised. 


Fig.  82. — (a)  Tupelo  and  (6)  Laminaria   Tents  beforb  and  after  Dilatation  by  Soaking  for  Eight? 

Hours. 


[While  no  other  tent  dilates  so  rapidly  or  produces  so  great  a  de- 
gree of  softening  of  the  uterine  tissues  as  one  of  compressed  sponge, 
their  use  is  entirely  abandoned  in  America,  because  of  the  difficulty 
of  rendering  and  keeping  them  sterile  and  the  great  danger  from 
septic  accidents  following  their  employment.  Their  place  is  very 
satisfactorily  taken  by  the  compressed  -tupelo  (made  from  the  strongly 
compressed  root-wood  of  the  Nyssa  uniflora,  Wang.)  which  can  be 
procured  of  any  necessary  dimensions,  has  little  tendency  to  become 
septic,  dilates  (about  100$)  rapidly  (in  from  four  to  eight  hours)  and 
gently,  causes  only  moderate  pain,  and  does  not  irritate  the  uterus 
excessively.     While,  as  I  have  said,  these  tents  have  little  tendency 


114  CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 

to  become  septic,  we  can,  if  necessary,  easily  render  their  sterility  ab- 
solute by  inclosing  each  one  in  a  small  sealed  paper  envelope  and 
baking  them  at  a  temperature  of  250°  F.  for  three  hours ;  the  envelope 
being  opened  only  at  the  moment  when  they  are  to  be  inserted. 
These  tents  are  especially  valuable  where  considerable  dilatation  is 
required,  as  in  cases  of  incomplete  abortion  with  contracted  os  or  be- 
fore the  removal  of  submucous  fibroids,  etc. 

Tents  are  ordinarily  best  introduced  through  the  Sims  speculum 
with  the  patient  in  the  Sims  position,  and  at  her  home  where  she  can 
be  kept  quiet  in  bed  during  the  period  of  their  insertion.  No  anaes- 
thetic is  required  for  their  introduction  or  removal,  but  in  many  in- 
stances pretty  severe  pain  is  felt  during  their  dilatation.  This  can 
best  be  relieved  by  a  powder  of  phenacetin  (gr.  iv.)  and  codeine  (gr.  i), 
which  I  prefer,  or  by  morphine.  The  tent  selected  should  be  one  which 
can  be  readily  passed  through  the  internal  os,  its  inner  extremity 
should  not  reach  much  above  this  point,  while  its  base  should  project 
somewhat  into  the  vagina  to  facilitate  its  removal.] 

B.  Divulsion. — The  advantage  at  times  of  immediate  dilatation 
by  force  has  given  birth  to  many  instruments  of  different  shapes  and 
powers.  The  dilator  of  Ellinger,  with  two  parallel  branches,  is  the  one 
I  prefer;  Schultze,  Sims,  and  others  have  invented  special  forms  of 
instruments.  But  they  are  all  objectionable,  since  they  take  their 
point  of  support  from  portions  which  are  liable  to  yield  and  tear 
under  the  strain,  and  by  themselves  they  do  not  suffice  to  make  a 
passage  admitting  the  index  finger.  The  Ellinger  dilator  is  very  ser- 
viceable and  convenient  for  facilitating  the  passage  of  the  sound  or 
the  curette  in  cases  of  cervical  constriction. 

[Palmer's  dilator,  with  the  intra-uterine  portion  of  the  blades  two 
and  a  quarter  inches  long  and  capable  of  dilatation  to  one  inch,  is 
most  convenient  and  efficient  for  general  use.  Where  a  more  powerful 
instrument  is  needed,  (xoodell's  modification  of  Ellinger,  with  blades 
two  inches  long,  corrugated  to  prevent  slipping,  and  opening  to  a 
width  of  one  and  a  half  inches,  is  one  of  the  best.  For  slight  degrees 
of  dilatation  an  anesthetic  is  not  necessary.  To  avoid  tearing  or  un- 
necessary injury  to  the  parts,  dilatation  should  always  be  done  slowly, 
occupying  from  ten  to  twenty  minutes,  with  the  least  possible  degree 
of  force  and  preferably  without  the  use  of  the  screw  attachment.  It 
should  be  done  through  the  speculum,  with  the  patient  either  on  the 
back  or  the  side,  the  vagina  being  filled  with  a  pool  of  antiseptic  fluid 
in  which  the  cervix  is  kept  immersed.] 


METHODS    OF   GYNAECOLOGICAL    EXAMINATION. 


115 


C.  Immediate  Progressive  Dilatation. — This  method  is  well 
known  to  surgeons,  who  apply  it  in  dilating  urethral  strictures  by 
means  of  graduated  sounds.  Of  these  there  are  many  devised  for  the 
use  of  the  gynaecologist;  Peaslee's,  which  are  actual  steel  sounds; 
Tait's,  of  conical  form ;  Hanks',  hard-rubber  and  ovoid ;  Fritsch's,  and 
lastly,  Hegar's,  which  are  the  most  practical.  They  are  cylindrical 
bougies  of  hard-rubber  with  conical  ends,  and  measure  twelve  to 
fourteen  centimetres  (four  and  one-half  to  five  inches)  in  length,  ex- 


Fig.  83. — a,  6,  Palmer's  Dilators  (b,  latest  model) ;  c,  Gcodell's  Dilator. 


elusive  of  the  flat  handle  (about  two  inches).  The  diameter  of  No.  1 
is  two  millimetres  and  they  increase  by  one  millimetre  per  bougie 
(three  millimetres  in  circumference);  this  increase  is  a  little  too  rapid 
for  the  higher  numbers,  and,  according  to  Hegar's  own  advice,  it  is 
well  to  have  some  bougies  for  difficult  cases,  which  increase  only  by 
half -millimetres.     They  should  be  kept  in  strong  carbolic  solution. 

To  use  them,  the  patient  is  anaesthetized  and  placed  in  the  dorso- 
sacral  position  (Hegar  prefers  Sims'  position),  the  fourchette  is  de- 
pressed with  a  short  blade,  the  anterior  cervical  lip  is  seized  and  fixed 


116  CLINICAL   AISTD    OPERATIVE   GYNAECOLOGY. 

with  a  hooked  forceps,  the  position  of  the  uterus  having  been  previ- 
ously determined  by  the  aid  of  bimanual  palpation  and  the  sound. 
Then  the  first  bougie  is  covered  with  vaselin  and  passed  in,  and  should 
be  of  a  calibre  which  enters  with  but  little  resistance.  Immediately 
afterward  a  second,  and  then  a  third  are  introduced,  and,  if  any  dif- 
ficulty is  encountered,  the  bougie  is  allowed  to  remain  from  one  to 
three  minutes  or  the  previous  one  is  introduced  a  second  time. 

When  the  cervix  is  naturally  or  artificially  softened,  it  is  possible 
to  reach  in  fifteen  minutes  a  sufficient  dilatation  to  admit  the  index 
finger.  When  the  cervix  is  dense,  an  hour  or  even  more  is  necessary. 
The  procedure  must  be  abandoned  if  there  is  risk  of  laceration  as  soou 
as  a  sufficient  dilatation  is  reached.  Hegar's  bougies  are  extremely 
useful  if  the  cervix  is  already  soft  and  dilatable,  as  it  is  directly  after 
abortion  or  parturition ;  when,  however,  the  cervix  is  rigid  through- 
out its  whole  length,  I  recommend  the  insertion  of  a  laminaria  tent 
for  ten  to  twelve  hours  to  produce  a  certain  degree  of  dilatation,. 


Fig.  84. — Hegar's  Dilator. 


softness,  and  dilatability,  and  at  the  time  of  its  removal,  the  rapid, 
completion  of  the  process  with  Hegar's  bougies. 

Operation  for  Rapidly  Dilating  the  Cervix  by  Incision. — Eapid 
-dilatation  of  the  cervix  with  a  cutting  instrument  may  be  indicated 
where  the  obstacle  to  be  overcome  in  passing  the  index  finger  within 
the  cervix  is  at  the  external  os  alone ;  when  there  is  a  special  urgency 
and  no  time  can  be  lost,  the  cervix  not  being  obliterated;  or  when  the 
surgeon  does  not  have  the  special  apparatus  needed  for  the  bloodless- 
method. 

A.  Incision  of  the  External  Os. — When  the  external  orifice  has 
spontaneously  enlarged  from  the  pressure  of  an  intra-uterine  polyp, 
abortion,  etc.,  a  simple  cut  in  either  side  of  the  os  will  suffice  for  the 
introduction  of  the  finger;  then  the  bloody  method  is  both  most 
simple  and  rapid.  Scissors  with  long  handles  are  used,  guided  by  the 
finger,  after  depression  of  the  fourchette  with  a  short  Simon's  blade 
and  fixation  of  the  cervix.  The  blades  of  ordinary  scissors  are  apt 
to  slip  and  therefore  Kiichenmeister's,  though  not  indispensable,  are 
to  be  preferred. 


METHODS    OF    GYNAECOLOGICAL    EXAMINATION. 


117 


An  incision  of  1  cm.  to  1.5  cm.  on  either  side  is  enough  for  the 
passage  of  the  index,  which  will  accomplish  the  required  dilatation 
itself.  After  the  exploration  is  complete,  the  uterus  should  be  irri- 
gated and  the  cuts  closed  with  catgut. 

B.  Complete  Bilateral  Division  of  the  Cervix. — This  procedure  is 
so  truly  an  operation  that  one  should  not  undertake  it  if  he  has  not 
already  a  large  experience  in  uterine  surgery.  A  necessary  prelim- 
inary is  ligation  of  the  uterine  artery.28  The  patient  being  anaes- 
thetized and  placed  in  the  dorso-sacral  position,  the  vagina  is  strongly 
retracted  upon  one  side,  while  the  cervix  is  drawn  with  a  tenaculum 
toward  the  opposite  side;  in  this  manner  one  of  the  lateral  vaginal 
pouches  will  be  exposed.  Then  a  long  and  strongly -curved  needle,  or 
better  a  Deschamp's  needle,  threaded  with  silk,  is  passed  through  the 
cul-de-sac  across  the  finger  outside  of  the  cervix,  taking  care  anteriorly 


Fig.  85.— Kuechenheister's  Scissors. 


not  to  go  beyond  a  line  tangent  to  the  circumference  of  the  cervix  at 
that  level  in  order  to  avoid  the  ureter.  The  surgeon  must  include  the 
greatest  possible  thickness  of  tissue  and  must  bring  his  needle  out  in 
the  vagina  posteriorly,  as  nearly  as  possible  to  the  point  of  entrance 
and  always  at  the  same  distance  from  the  os.  In  thus  keeping  the 
points  of  the  needle's  entrance  and  exit  close  together,  -the  surgeon 
endeavors  to  include  as  little  as  possible  of  the  vaginal  mucous  mem- 
hrane  within  the  loop  of  his  ligature.  The  silk  is  then  firmly  tied 
and  the  process  repeated  on  the  opposite  side. 

I  have  had  occasion  to  make  use  of  this  preliminary  ligation 
and  can  state  that  it  is  very  efficacious.  I  think  that  it  is  not  the 
main  trunk  of  the  artery  which  is  included  in  the  ligature,  but 
probably  its  inferior  branches;  however  that  may  be,  the  surgical 
xesult  is  excellent.  One  can  then  take  up  his  bistoury  with  no  fear 
of  hemorrhage.  The  cervix  being  drawn  down  is  incised  on  either 
side  to  the  vaginal  insertion,  and  then  an  attempt  is  made  to  intro- 


118  CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 

duce  the  finger;  should  this  still  be  difficult,  a  probe-pointed  bis- 
toury is  passed  in  along  the  index  and,  in  withdrawing  it,  the  cervix 
is  scored  on  its  internal  aspect  on  either  side,  until  the  finger  has  room 
enough  to  pass.  As  soon  as  the  exploration  has  been  finished,  and 
the  uterus  irrigated,  the  cervix  must  be  restored  with  great  care.  For 
this  purpose  a  needle  armed  with  catgut  is  passed  through  the  cervix 
at  the  level  of  the  vaginal  insertion,  so  deeply  that,  with  the  finger  as 
guide,  the  loop  of  the  ligature  lies  at  the  highest  point  of  incision 
within  the  cervical  canal.  It  is  well  to  make  all  the  stitches  on  both 
sides,  and  have  them  symmetrical,  before  drawing  the  first  tight;, 
otherwise  the  orifice  is  narrowed  at  once  and  the  finger  no  longer 
serves  as  a  guide.  The  first  two  superior  stitches  being  placed  and 
tightened,  a  sufficient  number  are  taken  below  to  adapt  the  mucous 
membranes  accurately,  both  within  the  canal  and  without. 

It  is  needless  to  leave  the  ligature  of  the  artery  indefinitely  in. 
place;  it  may  ulcerate  and  injure  the  vaginal  mucous  membrane;  it 
should,  therefore,  be  removed,  unless  there  are  special  indications  to 
the  iontrary,  at  the  end  of  three  or  four  hours.  Of  course  its  removal 
must  be  far  more  speedy  if  there  is  reason  to  fear  that  the  ureter  has 
been  tied,  but  this  accident  may  always  be  avoided  if  the  directions- 
given  are  minutely  observed. 

Permanent  Dilatation. — The  dilatation  obtained  in  one  of  these 
ways  may  be  maintained  by  tamjjoning  the  uterine  and  cervical  cavi- 
ties. The  idea  has  lately  been  current  that  continued  dilatation  favors, 
diagnosis  and  treatment  in  certain  uterine  affections,  since  it  exposes. 
the  parts  to  view. 

Vulliet,29  who  proposed  this  tempting  procedure,  thus  describes 
it:  The  patient  is  placed  in  the  genu-pectoral  position,  the  cervix  is 
exposed  by  a  Simon's  speculum,  and  its  canal  explored.  If  constricted 
or  misplaced,  its  natural  direction  and  calibre  are  restored  by  prelim- 
inary treatment ;  if  it  is  normal,  a  small  tampon  of  cotton  is  passed 
into  its  cavity  with  a  metal  sound.  These  tampons  vary  in  size  from 
that  of  a  pea  to  that  of  an  almond,  and  are  each  furnished  with  a. 
thread.  They  are  first  plunged  into  a  mixture  of  ether  and  iodoform 
(1 :  10),  then  dried  and  kept  in  a  well-stoppered  bottle.  Vulliet  intro- 
duces tampons  until  the  cervix  is  full  to  the  external  os.  These  he 
removes  at  the  end  of  forty-eight  hours.  If  it  has  been  well  stuffed, 
the  cervical  walls  have  become  soft  and  have  so  far  yielded  that  there 
is  free  space  for  the  operator,  who  at  once  takes  advantage  of  it  and 
packs  in  a  much  greater  number  of  tampons  than  before.     In  pro- 


METHODS    OF   GYNAECOLOGICAL   EXAMINATION.  119 

ceeding  thus  with  gradual  increasing  tamponade,  there  are  at  least 
eight  or  ten  repetitions  of  the  method  before  the  canal  is  so  wide  that 
it  may  be  seen  in  all  its  extent.  To  save  time  and  regulate  the  calibre 
of  the  cavity,  Vulliet  advises  that  the  tamponing  be  alternated  with 
laminaria  tents. 

This  procedure  is  not  always  applicable  in  the  conditions  indicated 
by  its  author.  There  are  a  certain  number  of  cases  where  the  requi- 
site calibre  cannot  be  obtained,  as  the  observations  of  Porak  and  Sabail 
demonstrate ;  and  there  are  other  cases  where  the  repetition  of  the 
tamponade  must  be  given  up,  either  because  of  the  pain  produced,  or 
because  of  nervous  accidents ;  these  latter  symptoms  appear  to  be  due 
to  the  nature  of  the  operation  itself,  not  to  the  absorption  of  iodoform 
from  poorly  made  tampons.  Moreover,  I  do  not  think  that  vision 
furnishes  more  satisfactory  information  about  the  uterine  cavity  than 
can  be  gained  by  the  different  exploratory  methods  already  described. 
Nor  do  I  think  that  therapeutics  have  been  greatly  advanced  by  this 
plan;  or  that  it  will  survive,  ingenious  as  it  may  be,  a  legitimate  in- 
terest, mixed  with  some  astonishment,  provoked  at  the  moment  of  its 
appearance. 

These  remarks  do  not  apply  to  haemostatic  or  antiseptic  tampon- 
ade (Fritsch's)  of  the  uterine  cavity,  for  I  believe  that  this  procedure 
will  be  retained  in  practice  and  more  frequently  employed. 

The  touch,  by  the  introduction  of  the  index  finger  into  the  uterine 
cavity,  takes  note  of  the  softness  or  villosity  of  the  mucous  membrane, 
of  vegetations,  tumors,  or  abnormal  projections  which  may  exist  there, 
and  the  manoeuvre  should  be  always  combined  with  hypogastric  pal- 
pation. It  must  be  very  rapidly  carried  out,  and  followed  by  an  intra- 
uterine injection  of  carbolic  solution  (1 :  100),  an  iodoform  tampon,  and 
absolute  rest  in  the  horizontal  position  for  two  days.  If  the  hemor- 
rhage occasionally  produced  does  not  yield  to  very  hot  injections 
(115°  to  120°  F.),  there  should  be  no  delay  in  filling  the  cavity  with 
iodoform  gauze  tampons  for  a  few  hours. 

Exploratory  Incision  and  Curetting. — Diagnosis  between  malig- 
nant and  benign  growths  is  so  important  from  an  operative  point  of 
view  that  we  should  not  hesitate  to  make  an  exploratory  incision  in 
doubtful  cases.  There  may  be  alterations  in  the  cervix  where  a  doubt 
as  to  their  nature  could  be  settled  only  by  an  operation  dangerous  to 
the  patient.  I  remember  an  excellent  instance :  My  regretted  master,. 
Gallard,  suspecting  cancer,  sent  me  for  operation  a  woman  who  had 
a  hard,  irregular  cervix  and  a  bloody  discharge.     Though  inclined 


120  CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 

to  accept  the  diagnosis,  it  was  with  some  reservation,  and  so  I  removed 
a  small  section  from  the  cervix ;  the  microscope  showed  simple  chronic 
inflammation.  She  had  escaped  another  snrgeon  who  was  just  about 
to  operate. 

This  mode  of  exploration  has  been  praised  by  clinicians  as  of 
great  value.30  The  technique  is  very  simple ;  fixation  of  the  cervix, 
excision  of  a  wedge-shaped  piece  with  sharp  scissors  or  a  bistoury, 
thermo -cautery  if  necessary  for  the  bleeding,  since  an  antiseptic  tam- 
pon may  allow  the  flow  to  continue. 

When  it  is  necessary  to  determine  the  state  of  the  uterine  mucous 
membrane,  scraping  it  with  a  cutting  curette  furnishes  us  with  shreds 
enough  for  examination.  Martin,31  who  is  a  great  partisan  of  this 
method,  advises  not  to  stop  with  partial  curettage,  but  to  make  it 
complete  and  follow  it  with  antiseptic  irrigation  and  the  injection  of 
(2  or  3  gm.)  perchloride  of  iron.  The  technique  of  the  process  will  be 
described  in  the  chapter  on  Metritis. 

Exploration  of  the  Ureters. — This  entire  subject  is  of  recent  date. 
In  1874,  Tuchmann  collected  the  urine  from  one  ureter  by  compress- 
ing the  other;  Hegar,  at  the  same  time,  proposed  tying  the  ureter  per 
vaginam  for  this  purpose.  But  it  is  not  until  very  recently  that 
Simon  (1875)  was  able  to  catheterize  the  ureter  by  the  guide  of  the 
finger  placed  in  the  bladder  after  urethral  dilatation.32  For  the  same 
purpose  Griinfeld  employed  the  endoscope.  But  Pawlik,33  in  1880, 
discovered  a  method  which  cannot  be  called  easy  and  yet  is  more  or 
less  practicable,  by  which  to  enter  the  ureter  directly  without  previ- 
ous operation,  guided  by  external  anatomical  landmarks.  Later 
labors  of  Newmann,34  Kelly,35  and  Byford 36  have  not  added  anything 
important  to  Pawlik's  method.  More  recently  Sanger37  (1886),  more 
clearly  defining  the  indications  already  sketched  by  Hegar,  Chrobak,38 
and  Pawlik,  attempted  to  introduce  into  practice  vaginal  palpation  of 
the  ureters;  I  have  seen  Pawlik  and  Sanger  demonstrate  their  method. 
Without  attempting  to  give  historical  details,  which  will  be  found 
complete  in  their  works  and  which  have  been  summed  up  by 
Schultz 39  in  a  recent  review,  I  will  simply  try  to  give  an  idea  of  the 
technique  of  these  two  skilled  gynaecologists. 

Reversing  the  chronological  order  for  the  logical,  I  will  describe 
Sanger's  method. 

A.  Palpation  of  the  Ureters. — The  anatomical  relations  of  these 
ducts  with  the  cervix  and  vagina  have  been  studied  with  especial 
rare  of  late  because  of  their  importance  to  the  success  of  certain  oper- 


METHODS    OF    GYNAECOLOGICAL    EXAMINATION. 


121 


utions  which,  have  become  the  order  of  the  day.40  As  is  well  known, 
it  is  possible  to  feel  through  the  vagina  the  anterior  pelvic  portion 
of  the  ureters,  if  injected,  in  the  cadaver,  just  where  they  open  into  the 
bladder  at  the  base  of  the  broad  ligaments ;  this  is  equal  to  a  length 
of  6  or  7  cm.  (2£  in.),  that  is,  the  greater  part  of  the  ureters  within  the 
pelvis  and  about  one-fourth  of  their  whole  length.  In  pregnant  women 
we  can  feel  as  much  as  10  cm.  (4  in.),  owing  to  the  general  muscular 
hypertrophy  which  all  the  pelvic  organs  undergo  at  that  time.     More- 


Fig.  86. — The  Portion  of  the  Ureters  Accessible  to  Touch.  0Hgure  diagrammatic;  the  posterior 
vaginal  wall  supposed  to  be  removed  and  the  ureters  visible  through  the  anterior  wall.)  a,  Base  of  broad 
ligament;  b,  ureter;  c,  cervix;  d,  ligament  between  the  ureters;  e,  trigonum  ;  /,  urethra;  g,  vagina. 


over,  one  can  take  his  supporting  point  from  the  head  of  the  foetus 
and  feel  the  ureter  against  that  structure. 

In  some  cases  of  gonorrhceal  and  calculous  inflammation  of  the 
ureters,  Sanger  was  able  to  diagnose  by  touch  that  they  wTere  remark- 
ably enlarged.  Where  there  is  a  chronic  inflammation  of  the  broad 
ligament  the  ureter  is  found  to  be  very  large  and  palpable  upon  the 
other  side,  as  if  from  hypertrophy.  Under  Sanger's  direction  I  have 
been  able  to  touch  the  ureters  in  pregnant  women,  but  on  attempting 
to  repeat  it  at  several  different  times,  the  result  has  always  seemed 


122  CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 

uncertain  to  me.  Probably  by  reason  of  the  great  difficulty,  and  the 
doubtfulness  of  its  results,  as  well  as  the  rarity  of  practical  conclu- 
sions furnished,  the  operation  is  not  likely  to  become  general.  To 
employ  the  method,  several  anatomical  points  must  be  held  clearly  in 
mind.  The  field  of  investigation  is  limited  to  the  upper  portion  of 
the  anterior  vaginal  wall.  Diagramatically  the  surface  is  a  trapezium 
with  oblique  and  divergent  sides  corresponding  to  the  union  of  the 
ureters  and  the  junction  of  the  anterior  with  the  lateral  vaginal  wall. 
The  small  base  of  this  trapezium,  which  is  really  the  truncated  apex  of 
a  triangle,  is  placed  below  and  horizontally,  corresponding  to  the  liga- 
ment between  the  ureters;  the  larger  base  is  above,  formed  by  the 
j)oint  of  exit  of  the  ureters  from  the  broad  ligaments  and  a  line 
joining  them.  In  this  space  the  finger  encounters,  in  certain  circum- 
stances, 1  or  2  cm.  (£  to  f  in.)  behind  the  os  externum,  in  the  depth  of 
the  vaginal  pouch,  two  hard,  longitudinal  cords,  one  on  each  side, 
directed  from  without  inward  and  from  below  upward,  making  a 
curve  which  is  concave  inward  (Fig.  86, 5).  One  cannot  ordinarily  trace 
them  through  their  whole  accessible  length,  which  is  6  or  7  cm.  (2|- 
in.)  to  the  base  of  the  trigonum ;  about  2  cm.  is  all  that  can  be  usually 
palpated. 

The  ureters  are  normally  symmetrical,  but  they  cease  to  be  so  after 
different  lesions,  and  then  their  direction  may  vary  from  cicatricial 
contraction  so  much  that  the  ureter  of  one  side  may  be  found  Upon 
the  other;  or  their  concavity  may  be  directed  upward  instead  of  in- 
ward ;  or,  finally,  but  one  ureter  may  be  palpable. 

The  average  normal  diameter  of  the  ureters  is  1  mm.,  but  diseased,, 
it  may  reach  the  volume  of  a  goose-quill  or  even  a  large  crayon. 
They  are  more  or  less  movable  under  the  finger,  or  fixed  in  place  by 
inflammation,  and  normally  they  are  not  sensitive  to  pressure,  though 
they  may  become  so  if  diseased. 

To  touch  them  by  the  vagina  one  must  jDroceed  in  the  following 
way.  With  the  index,  trace  up  the  urethra  to  its  exit  from  the  blad- 
der, which  brings  the  finger  into  the  anterior  vaginal  pouch ;  there 
notice  the  direction  of  the  cervix.  To  find  the  ureter  we  must  seek  in 
that  portion  of  the  anterior  vaginal  wall  which  is  comprised  between 
the  internal  orifice  of  the  urethra  and  the  anterior  vaginal  cul-de-sac. 
This  region  has  an  extent  of  not  more  than  2  to  5  cm.  (f  to  2  in.)  and 
is  remarkable  for  its  loose  attachments.  With  the  lateral  surface  of 
the  tip  of  the  finger  the  vaginal  wall  is  palpated  to  the  front  and  side 
in  the  direction  of  the  broad  ligament,  using  the  finger  corresponding 


METHODS    OF   GYNAECOLOGICAL   EXAMINATION.  123 

to  the  ureter  sought.  The  left  index  can  be  used  for  the  right  ureter 
and  vice  versa,  but  in  that  case  it  is  the  palmar  surface  which  pal- 
pates. It  is  necessary  to  work  gently,  with  a  gliding  motion,  and  not 
by  frequently  applying  and  removing  the  finger.  Delicate  palpation 
demonstrates  whether  the  ureters  are  normal  or  a  little  hypertrophied ; 
they  have  the  feel  of  an  artery  deprived  of  its  pulsation.  When  one 
can  compress  them  against  a  hard  body,  like  the  pelvic  bones  or  the 
foetal  head,  they  roll  about  within  their  sheaths.  Palpation  is  more 
readily  accomplished  when  the  vaginal  wall  is  very  flaccid. 

The  ureters  must  not  be  confounded  with  arteries,  cicatricial  bands 
about  the  uterus,  or,  according  to  Sanger,  with  the  levator  and  sphinc- 
ter ani.  These  errors  may  be  avoided  if  one  takes  strict  account  of 
both  their  anatomical  and  their  abnormal  positions.  It  is  none  the 
less  very  difficult,  without  special  training,  to  employ  with  profit  this 
new  exploratory  method  of  the  eminent  Leipsic  gynaecologist. 

Catheterism  of  the  Ureters. — Pawlik's  method.  It  was  during 
his  stay  in  Vienna  as  privat-docent  that  Pawlik,  now  professor  at  the 
university  of  Prague,  made  his  first  experiments  toward  his  ingenious 
method  in  a  case  of  doubtful  diagnosis  occurring  in  Billroth's  clinic. 
I  had  an  opportunity  at  the  time  of  seeing  and  verifying  the  marvel- 
lous dexterity  with  which  he  accomplished  the  delicate  manoeuvre. 
There  are  cases  where  it  is  of  the  greatest  importance  to  determine 
whether  both  kidneys  are  diseased  or  only  one ;  Pawlik  made  the 
matter  perfectly  clear  on  one  memorable  occasion,  and  on  another 
diagnosed  a  hydronephrosis  and  allowed  the  ureteral  sound  to  remain 
in  position.  For  this  latter  procedure,  he  constructed  a  special  in- 
strument (Fig.  88),  but  it  is  not  free  from  all  danger;  for  the  metal 
piece  which,  in  this  instrument,  is  fastened  to  the  long  rubber  sound, 
could  not  be  removed,  *f  separated,  without  an  unusually  fortunate 
combination  of  circumstances. 

Certain  anatomical  points  must  be  clearly  understood  beforehand 
in  order  to  use  Pawlik's  method.  In  front  of  the  lowest  part  of  the 
bladder,  on  the  posterior  portion  of  the  antero-inferior  wall,  the  ure- 
ters are  found  at  the  posterior  angles  of  the  trigone,  and  the  anterior 
is  occupied  by  the  urethra.  Each  of  the  three  orifices  is  at  the  top  of 
a  papilla,  which  is  more  or  less  prominent,  of  an  irregular  cylindrical 
form,  made  by  a  thickening  of  the  muscular  coat  and  invested  by 
mucous  membrane.  These  papillae  serve  as  land-marks.  They  are,, 
moreover,  connected  by  a  marked  band  of  the  same  formation,  convex 
forward,  thick  and  resistant  enough  to  hold  the  point  of  a  sound  nt 


124 


CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 


its  middle  (Pawlik),  where  it  is  somewhat  thinned,  and  to  be  appreci- 
ated by  direct  palpation  (Simon).  This  fold  is  called  the  inter-ureteral 
ligament,  the  pad  or  muscle  of  the  ureter;  it  forms  the  curved  base 
of  Lieutaud's  triangle,  the  other  sides  being  indicated  by  less  marked 
folds  which  point  toward  the  urethra  and  become  thinner.  The  di- 
mensions of  this  triangle  are  naturally  inconstant,  but  it  is  usually 
almost  equilateral.     Its  base  is  estimated  at  2  cm.  6  mm.  to  4  cm.  (f  to 


Fig.  87.— The  Vesical  Trigone  (Pawlik).  L,  L,  Labia  minora;  O,  urethral  orifice;  O',  0',  urethral 
■cushion;  V,  os  externum;  B,  fold  of  mucous  membrane,  behind  inter-ureteral  ligament,  forming  base  of 
triangle;  S,  S,  lateral  fold,  converging  and  corresponding  to  the  sides  of  the  triangle. 

li  in.)  (Simon,  Quain,  Hyrtl);  its  sides,  at  2  cm.  7  mm.  (Simon),  2  cm., 
and  2  cm.  8  mm.  (Warnoots)  or  at  4  cm.  (Hart)  (1  to  1|-  in.).  The  dis- 
tance between  the  urethral  opening  and  the  middle  of  the  base  is 
given  as  1  cm.  to  2  cm.  (Warnoots)  to  3  cm.  (Hart)  (f  to  l|  in.). 

Pawlik  has  the  patient  put  in  the  genu-pectoral  position,  but  one 
can  quite  as  well  do  the  operation  in  the  dorso-sacral ;  it  is  only  nec- 
essary in  the  latter  position  to  have  the  head  well  lowered  and  the 
buttocks  strongly  raised,  that  the  viscera  may  fall  toward  the  dia- 


METHODS    OF    GYNECOLOGICAL    EXAMINATION. 


125 


phragm.     -A  Simon's  speculum,  as  large  as  possible,  is  put  into  the 
vagina  and  the  posterior  wall  depressed;  the  an- 
terior wall  is  thus  perfectly  stretched. 

This  tension  of  the  anterior  vaginal  wall  al- 
lowed Pawlik  to  note  certain  permanent  folds  of 
great  importance  topographically.  He  mentions 
near  the  external  orifice  of  the  urethra  a  pad  or 
cushion  elongated  from  before  backward  in  the 
median  line,  folded  or  furrowed  transversely  and 
well  marked,  which  corresponds  to  the  course  of 
the  urethra  within  the  wall  (tubercle  and  ante- 
rior column  of  the  vagina).  This  fold  terminates 
at  the  internal  meatus.  Next  there  follows  a 
triangular  space  corresponding  to  the  base  of  the 
bladder  or  the  trigone  of  Lieutaud.  This  space 
is  bounded  posteriorly  by  the  inter-ureteral  liga- 
ment, slightly  convex  forward,  having  the  orifice 
of  a  ureter  at  each  end  of  it.  The  lateral  folds 
diverge  from  before  backward  aud  end  about 
1  cm.  (f  in.)  behind  the  internal  meatus,  thus  form- 
ing the  truncated  apex  of  the  triangle  (Fig.  89). 

It  can  be  demonstrated  upon  the  cadaver  that 
the  vaginal  triangle  thus  bounded  corresponds 
line  for  line  with  the  intra-vesical  trigone  of 
Lieutaud,  and  should  therefore  be  called  Paw- 
lik's  vaginal  trigone.41 

Pawlik  uses  a  catheter  which  has  a  probe- 
pointed  extremity,  about  25  cm.  in  length  with  a 
tip  of  1.5  mm.  diameter;  the  eye  of  the  catheter 
is  very  much  elongated,  with  bevelled  edges,  and 
is  situated  on  the  base  of  the  point  of  the  in- 
strument on  a  slight  curve  continuous  with  the 
main  stem,  which  tapers  a  little.  At  1.5  cm. 
from  the  other  end  of  the  catheter  is  attached  a 
holder,  of  octahedral  shape,  which  carries  a  mark 
corresponding  to  the  curve  of  the  instrument, 
and  beyond  this  handle  the  tube  projects  for 
about  1.5  cm.  more.  fig.  ss-pawlik/s  ureteral. 

Catheters,    a,  W  ith  stylet :  b, 

To  render  the  instrument  aseptic  the  stylet  is  permanent  form  -with  rubber 

..-i    -,  -i    ,-i  -i       -i  ,        •  ,-i      tube  which  is  passed  through  a, 

withdrawn  and  the  instrument  washed  out  with  metal  sheath. 


126  CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 

water;  then  it  is  filled  several  times  with  ether,  and  finally  passed 
through  an  alcohol  flame.  Before  introducing  the  catheter,  there 
should  be  a  certain  degree  of  vesical  distention,  and  the  shortest  and 
surest  way  to  obtain  this  is  to  empty  the  bladder  completely  and  then 
inject  (200  cc.=6  oz.)  of  water,  which  is  plenty  for  moderate  distention. 
The  urethral  catheter  is  then  removed  and  the  ureteral  passed  in. 

As  soon  as  this  instrument  has  passed  within  the  internal  meatus, 
the  other  end  of  it  should  be  raised  so  that  the  tip  shall  be  brought 
toward  the  recto-vaginal  pouch  at  the  level  of  the  trigone.  As  the 
instrument  is  pushed  gently  in,  its  beak  makes  a  slight  prominence 
on  the  anterior  vaginal  wall,  and  as  it  passes  onward,  this  prominence 
changes  its  place;  thus  the  catheter  can  be  guided,  following  the  sides 
of  the  vaginal  trigone  and  moving  from  within  outward  and  behind 
forward,  toward  the  orifice  of  the  ureter.  In  this  direction  it  meets 
the  inter-ureteral  ligament  or  fold  at  its  most  projecting  outer  part; 
while,  if  it  is  held  in  the  median  line,  it  may  pass  over  the  middle  of 
the  fold,  where  it  is  flattest,  and  so  miss  it  entirely.  Arriving  at  the 
ureteral  orifice,  it  is  held  there  while  small  movements  of  gliding,  ro- 
tation, elevation,  and  depression  are  made,  until  it  has  passed  in ;  but 
always  without  leaving  the  angle  of  the  trigone,  which  is  kept  con- 
stantly before  the  eye.  Once  within  the  ureter,  the  instr anient  is 
pushed  1  or  2  cm.  ( i  in.)  toward  the  posterior  vesical  wall.  The  en- 
trance of  the  catheter  is  appreciated  by  the  sudden  removal  of  all 
resistance ;  it  advances  as  into  an  empty  space;  while,  on  the  contrary, 
lateral  and  downward  movements  of  the  handle  are  resisted  more  and 
more  as  the  instrument  advances.  At  the  end  of  a  certain  time  the 
urine  flows  in  a  jerky  stream,  while,  as  is  well  known,  from  the  blad- 
der it  would  be  continuous.  If  the  catheter  is  passed  still  further  in,  it 
changes  its  direction  at  the  superior  strait  and  then  it  is  time  to  arrest 
the  procedure  on  account  of  its  difficulty,  which  is  specially  great 
where  the  urethra  is  tightly  fastened  to  the  os  pubis  and  but  little 
dilatable,  as  in  nulliparae ;  if,  however,  the  urethra  is  large  and  soft- 
walled,  the  catheter  may  be  passed  still  further.  It  should  be  pushed 
on  with  the  greatest  gentleness  as  the  other  end  is  depressed  as  far  as 
possible.  On  the  other  hand,  this  latter  half  of  the  process  is  as  easy 
as  the  first,  when  one  has  entered  a  fistula  in  the  bladder  or  urethra. 
I  once  was  able  to  pass  Pawlik's  sound  to  the  pelvis  of  the  kidney," 
but  it  was  not  per  urethram.  I  had  introduced  it  into  a  vesico-vaginal 
fistula  which  I  had  reason  to  suspect  was  connected  with  the  ureter, 
and  I  was  able  to  confirm  the  diagnosis. 


METHODS    OF   GYNAECOLOGICAL    EXAMINATION. 


127 


Thus  one  may  reach  the  pelvis  of  the  kidney;  the  ureter  is  then 
dragged  into  a  straight  line.  Ordinarily  in  contact  with  the  pelvic- 
wall,  it  is  then  pulled  away  to  a  distance  of  about  4.5  cm.  (If  in.), 
but  the  cellular  tissue  which  surrounds  it  will  permit  this  degree  of 
displacement  if  it  is  in  normal  condition;  ureteral  catheterism  should 
therefore  be  carried  out  with  the  utmost  gentleness,  especially  if  there 
is  reason  to  suspect  any  inflammation  about  these  tubes. 

The  only  troublesome  results  which  I  have  been  able  to  verify,  are 
fever,  abdominal  pain,  which  does  not  last  more  than  twenty-four 


TrL 


Fig.  89.— Ureteral  Catheterism  bt  Simon's  Method.  The  instrument  is  slid  along  the  finger  whose 
tip  rests  upon  the  inter-ureteral  ligament,  a,  a,  a,  base  of  the  bladder;  b,  b,  orifices  of  the  ureters  : 
Tr  L,  Lieutaud's  triangle. 


hours,  or  a  slight  degree  of'  peritonitis  (in  a  case  where  it  had  already 
been  present) ;  in  the  urine,  furthermore,  we  may  find  blood,  epithelial 
debris,  products  of  traumatism  of  the  ureter.  It  seems  possible  that 
there  might  be  a  ureteral  fever,  similar  to  the  urethral,  which  would  be 
a  serious  accident  to  follow  such  catheterism.  We  must  wait  till  the 
procedure  has  been  more  frequently  employed  before  observations 
become  numerous. 

Simon'' s  Method. — If  exploration  of  the  ureter  is  considered  neces- 
sary and  Pawlik's  method  cannot  be  carried  out  after  several  at- 
tempts, then  Simon's  method  may  be  enrployed;    which   comprises 


128  CLINICAL   AND   OPEEATIVE   GYNAECOLOGY. 

anaesthesia,  urethral  dilatation,  introduction  of  the  catheter  along  the 
ringer,  which  immediately  feels  the  inter-ureteral  ligament.  Incontin- 
ence of  urine  need  not  deter,  for  it  seldom  lasts  long.  This  older 
form  should  be  adopted  where  the  operator  has  had  no  special  train- 
ing in  Pawlik's  method,  as  being  the  more  certain  of  the  two.  Differ- 
ent plans  have  been  proposed  for  compressing  or  tying  the  ureter  from 
the  vagina  for  diagnostic  purposes.  Narkalla  42  has  recently  lauded 
exploratory  compression  by  a  thread  passed  over  the  ureter  from  the 
vagina.  He  succeeded  in  doing  this  on  the  cadaver  ten  times  in 
thirty.  According  to  this  author  the  operation  offers  no  danger, 
since  instead  of  tying  the  thread,  he  merely  used  gentle  traction 
upon  it,  to  shut  off  the  ureter  temporarily.  I  prefer  catheterism  to 
this  manoeuvre. 


BIBLIOGRAPHY. 

1.  Fritseh  :   Centr.  f.  Gyn.,  1886,  No.  14. 

2.  Doran  :  Handbook  of  Gynaecology,  1887,  page  134. 

3.  Meyer:  Arch.  f.  klin.  Chir.,  Bd.  xxxi.,  p.  514. 

4.  Mendes  de  Leon :  Ein  neues  Untersuchungsverfahren.  Centr.  f.  Gyn., 
1888,  No.  21. 

5.  Munde  :  Minor  Surg.  Gynaecol.,  2d  Ed. 

6.  Bozeman  :   Vesico-vaginal  Fistula,  New  York,  1869. 

7.  A.  Winawer  :  Ueber  die  Thure-Brandt1sche  Methode  als  Mittel  die  erkrank- 
ten  Tuben  palpirbar  zu  machen.     Centr.  f.  Gynak.,  1888,  No.  52. 

8.  S.  Pozzi :   Annales  des  Maladies  des  Organes  G6nito-urinaires,  May  1st,  1883. 

9.  Mallik  :  Centr.  f.  Gyn.,  1887,  No.  24  ;  and  Terrillon  :  Ann.  de  Gyn.,  Oct.,  1886. 

10.  Asch:   Centr.  f.  Gyn.,  1887,  page  426. 

11.  Bull,  de  la  Soc.  Anat.,  xlvii.,  page  190,  April,  1872. 

12.  Brault :  De  la  Terininaison  par  Gangrene  des  Corps  Fibreux  Intra-uterins. 
Thesis.  Paris,  1883. 

13.  Recauiier  :  Gaz.  des  Hop.,  1850,  page  74  ;  and  Nelaton  :  Gaz.  des  H6p.,  1852, 
page  57. 

14.  Simon  :  Ueber  die  kiinstliche  Erweiterung  des  Anus  und  Rectum.  Lan- 
genbeck's  Archiv  f.  Chir.,  Bd.  xv.  Ueber  die  manuelle  Rectal  palpation  der  Becken- 
und  Unterleibes-Organe.     G5schen's  Deutsche  Klinik,  1872,  No  41. 

15.  Landau  :  Ueber  den  diagnostischen  Werth  der  Rectaluntersuchung  mit 
der  Vollenhand  in  gynakologischer  Beziehung.  Archiv  f.  Gynak.,  Bd.  vii.,  p.  541. 
Weiss  :   The  New  York  Med.  Record,  March  21st,  1875. 

16.  Curschmann  :  Obst.  Soc.  of  Hamburg,  January  21st,  1888.  Centr.  f.  Gyn., 
No.  20,  1888. 

17.  Noeggerath  :  The  Vesico-vaginal  and  Vesico-rectal  Touch.  Amer.  Journal 
of  Obstetrics,  May,  1875.  G.  Simon  :  Ueber  die  Methoden  die  weib.  Blasenhohle 
zuganglich  zu  machen.  Arch.  f.  klin.  Chirurg.,  Bd.  xv.,  p.  127.  Longuet :  De  la 
Dilatation  de  l'Urethre  chez  la  Femme.     Annales  de  Gyn.,  i.,  p.  216. 

18.  Schultze  :  Jenaische  Zeitsch.  f.  Med.  und  Nat.,  Leipsic,  i.,  p.  279,  1864. 

19.  Ulmann :   Centr.  f.  Gyn.,  1888,  No.  12. 

20.  Caulet :   Bull,  de  la  Soc.  de  Chir.,  1887,  page  439, 


METHODS    OF    GYNAECOLOGICAL   EXAMINATION.  129 

21.  Winter  :  Die  Microorganisinen  in  Genitalkanal  der  gesunden  Frau.  Zeit. 
f.  Geb.  und  Gyn.,  Bd.  xiv.,  Heft  2. 

22.  Bischoff  :  Corresp.  f.  Schw.  Aerzte,  No.  19,  and  Biedert  :  Ueber  Sondirung 
der  Tuba  Fallop.  und  iiber  Ursachen  und  Folgen  der  Tubenerweiterung.  Berliner 
klin.  Wochenschrift,  1STT,  Nos.  41  and  42. 

23.  Conner:  Zwei  Falle  von  Tubensondirung.  Archiv  f.  Gynak.,  Bd.  xxx., 
Heft  1. 

24.  Lawson  Tait :  Uteroperitoneal  Fistula.  Lancet,  Oct.  19th,  1S71  ;  ibidem, 
January.  1875.  Valenta :  Grazer  Naturforscherversauimlung,  1875 ;  Tagblatt,  p. 
116. 

2.3.  Hegar  and  Kaltenbach  :  Die  operative  Gynakologie,  1874,  page  40. 
2G.  Porak  :  Dilatation  de  FUterus  a  I'Aide  de  Tentes  Aseptiques,  etc.     Nouv. 
Arch.  d'Obst.  et  de  Gynec,  June,  July,  August,  1887. 

27.  Sloan  :   Glasgow  Med.  Journal.  October,  1862. 

28.  Schroeder  :  Zeit.  f.  Geb.  und  Frauenkrankh.,  vi.,  page  289,  and  Martin: 
Path,  und  Ther.  der  Frauenkrankh.,  2d  ed.,  1887,  page  26. 

29.  Betrix  :  De  la  Nouvelle  Methode  du  Professor  Vulliet  pour  Obtenir  la  Dila- 
tation de  la  Cavite"  Uterine.  Nouvelles  Archives  d'Obst.  et  de  Gyn.,  1886,  p.  33. 
Charpentier  :  Les  Nouvelles  Methodes  de  Dilatation  Totale  de  l'Uterus.  Ibidem, 
p.  693.  Vulliet :  De  la  Dilatation  de  rUterus  par  le  Procede  des  Obturations  Pro- 
gressives.    Ibidem,  1887,  p.  466. 

30.  Richter:  Berliner  klin.  Wochensch.,  1879,  No.  1.  C.  Huge  :  Ibidem,  No.  4. 
Huge  and  Veit :  Zeitsehr.  f.  Geburtshiilfe  und  Gynak.,  vii.,  Heft  1.  ATeit :  Centr. 
f.  Gynak.,  187S,  No.  26. 

31.  A.  Martin  :   Path,  und  Ther.  der  Frauenk.,  2d  ed.,  1887,  p.  30. 

32.  Simon  :   Yolkmann's  Sammlung  klin.  Yortrage,  No.  38. 

33.  Pawlik :  Ueber  die  Harnleiter-Sondirung  beim  Weibe.  Langenbeck's 
Archiv,  Bd.  xxxhi.,  Heft  3.  This  paper  contains  the  complete  history  of  the  ques- 
tion. 

34  Newman :  British  Med.  Journal,  July  2Sth,  1885,  and  Glasgow  Medical 
Journal,  July,  1885. 

35.  Kelly  :  Obstet.  Soc.  of  Philadelphia.  Amer.  Journal  of  Obstetrics,  xx.,  p. 
1.294.     Hirst  :   Ibidem,  xxi.,  p.  318. 

36.  W.  Byford  :  The  Practice  of  Medicine  and  Surgery  applied  to  the  Diseases 
and  Accidents  incident  to  "Women,  4th  Edit.,  Philadelphia,  1888. 

37.  Sanger :  Ueber  Tastung  der  Harnleiter  beim  Weibe.  Archiv  fur  Gyn., 
xxviii.,  p.  54.  Compare  the  important  discussion  at  the  Gynaecological  Congress  at 
Munich  on  Sanger's  paper.  Yerhandlungen  der  Deutschen  Gesellschaft  fur  Gynak., 
first  Congress,  Leipsic,  1886,  page  64. 

38.  Hegar  and  Kaltenbach  :  Operative  Gynak.,  2d  ed.,  p.  42.  Chrobak  :  Hand- 
buch  der  Frauenk.,  3d  ed.,  i.,  p.  37. 

39.  D.  Schultz  :  Exploration  des  Ureteres  chez  la  Femme.  Nouvelles  Archiv. 
d'Obst.  et  de  Gyn.,  1887,  pp.  205-262. 

40.  Garrigues  :  Remarks  on  Gastro-elytrotomy.  Amer.  Gynsc.  Transactions, 
vol.  iii.,  p.  212.     Ricard  :   Semaine  medicale,  February  2d,  1887. 

41.  Zweifel  :  Obst.  Soc.  of  Leipsic,  October  17th,  1887.  Centr.  f.  Gynak.,  1888, 
p.  440. 

42.  Narkalla:  Arch.  f.  Gynak.,  Bd.  xxix.,  H.  2. 


CHAPTER  V. 
THE   PATHOLOGY  AND   ETIOLOGY   OF   METRITIS. 

Definition. — According  to  its  etymology,  metritis  is  inflammation 
of  the  uterusy  and  I  shall  hold  to  this  general  definition  although  it 
might  call  for  a  long  commentary.  But  it  is  enough  that  I  am  under- 
stood, and  the  word  has  a  decided  clinical  value.  The  generic  term 
inflammmation  is  applicable  to  all  morbid  states  where  the  anatomi- 
cal substratum  is  reduced  by  irritative  lesions  without  resulting  in 
the  formation  of  specific  neoplasms.  How  numerous  and  varied  these 
lesions  may  be  we  shall  soon  discover.  But  they  are  all  to  be  grouped 
under  the  same  head  because  of  the  infectious  nature  of  their  origin 
as  well  as  by  their  defensive  character  and  limited  evolution.  When 
there  is  mucous  or  parenchymatous  proliferation,  the  entire  process 
takes  place  as  circumscribed  local  irritation,  coming  to  a  focus  either 
externally  or  internally,  with  no  tendency  to  pass  certain  bounds; 
this  distinguishes  inflammation  from  neoplasms  properly  so-called. 
Do  there  exist,  aside  from  metritis,  "  morbid  states  without  neoplasm  " 
which  need  to  be  distinguished?  Basing  their  opinion  upon  dogmatic 
ideas  and  a  narrow  conception  of  inflammation,  the  ancient  authors 
did  not  hesitate  to  reject  from  the  class  of  metritis  all  states  which 
did  not  fall  under  the  fourfold  division  of  "tumor,  rubor,  calor, 
dolor."  Granulations,  ulcerations,  and  leucorrhoea  belonged  in  con- 
sequence to  other  diseases.  There  are  traces  of  this  scholastic  preju- 
dice to  be  found  even  up  to  the  modern  writers,  Alph.  Guerin  and 
Courty.1  Does  not  the  latter  author  devote  separate  chapters  to  flux- 
ion (inflammation),  congestion,  engorgement,  oedema,  hypertrophy, 
subinvolution,  and  granulation  and  ulceration  of  the  cervix  ?  It  is 
necessary  only  to  run  the  eye  along  his  tables,  so  laboriously  prepared 
with  the  view  of  differential  diagnosis  of  the  various  morbid  entities, 
to  be  at  once  convinced  of  the  folly  of  parallel  tabulations. 

A  very  necessary  distinction  is  the  following:  the  idea  of  the 
lesion  must  not  be  confounded  with  the  disease.  This  is  what  the 
various  authors  wish  to  indicate  by  the  use  of  the  terms  idiopathic 


THE    PATHOLOGY   AZSD    ETIOLOGY    OF   METRITIS.  131 

and  symptomatic  metritis;  ill-chosen  language  which  we  will  not 
adopt.  The  word  metritis  should  remain  a  clinical  term  and  not  a 
pathological.  It  is  thus  that  we  shall  study  the  malady  and  its  path- 
ology is  but  the  supplement  thereto.  Because  there  are  lesions  of 
endometritis  with  a  fibroma,  or  of  metritis  with  carcinoma,  shall  we 
therefore  describe  a  myomatous  and  a  carcinomatous  metritis  ?  That 
would  have  but  one  effect — confusion. 

Truly  our  distinctions  are  somewhat  artificial,  because  they  must 
be  sharply  defined  and  there  is  nothing  absolute  in  nature ;  they  are 
none  the  less  indispensable,  and  quite  justifiable  if  one  is  careful  to 
explain  upon  what  criterion  they  are  founded.  I  have  already  said 
that  ours  is  clinical;  it  is  the  only  one  which  gives  personality  to  a 
disease.  I  cannot  leave  the  subject  without  a  few  words  on  pseudo- 
metritis,  the  so-called  symptomatic  metritis.  Inflammatory  changes 
in  the  uterine  mucous  membrane  are  almost  constant  with  fibromata, 
and  to  this  fact  we  may  undoubtedly  ascribe  the  bleeding.  TVyder's 2 
monograph  on  the  subject  is  very  complete.  The  irritation  in  these 
cases  travels  by  continuity  step  by  step.  In  the  same  manner,  but  in  a 
reverse  direction,  it  can  follow  reflex  congestions,  which  predispose  to 
infection,  after  disease  of  the  adnexa.  This  pseudo-metritis,  as  I  have 
termed  it,  has  been  classified  by  Czempin3  under  different  heads 
according  to  the  point  of  origin  as  follows : 

1.  Chronic  oophoritis,  of  one  or  both  sides,  with  or  without  parti- 
cipation of  the  tubes. 

2.  Exudative  parametritis  with  exacerbations. 

3.  Pelvic  peritonitis  after  removal  of  ovaries  or  tubes,  starting 
in  cicatrices  of  the  broad  ligaments. 

4.  Tumors  of  slow  growth  in  the  adnexa  (pyo-salpinx,  sarcoma,  and 
carcinoma  of  the  ovary). 

The  peculiar  characteristic  of  pseudo-metritis  is,  that  the  inflam- 
mation of  the  uterine  mucous  membrane  is  merely  an  epi-phenomenon 
of  tardy  development  and  not  appearing  at  the  first  onset,  which 
becomes  evident  only  after  the  appearance  of  disease  in  the  adnexa 
or  the  pelvic  peritoneum. 

Brennecke,4  even  before  Czempin,  had  described  a  hyperplastic 
ovarian  metritis,  occurring  chiefly  at  the  menopause,  marked  b'y  con- 
tinued or  typical  hemorrhages,  and  equivalent  to  the  hyperplastic  form 
upon  which  Olshausen  insisted. 

Classification. — Turning  now  to  the  study  of  metritis  proper,  and 
its  various  forms,  if  we  consult  the  authors  we  shall  find  the  most 


132 


CLINICAL   A3STD    OPERATIVE   GrYJSTJECOLO^Y. 


widely  different  starting-points  for  classification ;  they  take  the  prog- 
ress of  the  disease  and  term  it  acute  and  chronic ;  or  the  location  of 
it,  and  describe  cervical  and  corporeal  endometritis,  parenchymatous 
and  idio-metritis ;  or  from  its  cause,  it  is  puerperal,  post-puerperal, 
gonorrhceal,  traumatic,  etc. ;  or  from  its  pathology,  it  is  styled  gran- 
ular, fungous,  ulcerating,  etc.  For  our  purpose  these  schemes  all  have 
the  defect  of  being  as  systematic  and  artificial  as  Linneus'  classifica- 
tion of  plants.  They  are  founded  upon  some  character,  arbitrarily 
chosen,  whose  value  is  not  so  great  that  all  authors  should  be  fairly 
dominated  by  it.     But  in  order  to  reach  a  classification  as  natural  as 


Qv^ .  ^y.CT^gjy^. 


liSiSKES^- .£. 


Fig.  90.— Normal  Mucous  Membrane  of  the  Body  of  the  Uterus,1  slig fitly  Enlarged  (Wyder). 

(Mucous  surface  to  the  left;  muscular  tissue  to  the  right.) 
To  the  naked  eye  the  uterine  mucous  membrane  differs  from  the  cervical  in  being  smoother.  Under 
the  microscope  it  is  seen  to  consist  of  collections  of  embryonal  cells  and  tubular  glands.  These  embryonic 
connective  tissues  are  essentially  homogeneous,  rich  iu  round  and  fusiform  cells,  which  are  found  scattered 
through  the  muscular  base  of  the  membrane,  along  the  vessels  and  glands,  and  here  and  there  in  the  thick- 
ness of  the  tissues;  both  forms,  especially  the  round  cells,  are  characterized  by  their  single  large  nucleus 
surrounded  by  a  thin  layer  of  protoplasm.  The  tubular  glands  cross  the  interglandular  tissue  almost 
perpendicularly,  and  at  the  muscular  layer  are  branched,  piercing  the  thin  layer  between  the  connective- 
tissue  bands  which  separate  the  muscular  bundles.  The  limit  between  muscle  and  membrane  is  sharply 
cut  throughout.  The  surface  of  the  mucous  membrane  is  covered  with  a  single  layer  of  ciliated  cylindri- 
cal epithelium.  The  mucous  membrane  of  the  body  is  further  distinguished  by  the  wealth  of  its  arterial 
supply  and  the  poverty  of  its  venous.  The  arterioles  pierce  the  layer  perpendicularly,  give  off  many  little 
branches  which  enter  the  glands,  then  recurve  and  cross  immediately  below  the  epithelial  investment, 
forming  an  irregular  plexus  of  large  capillaries,  whence  the  veins  originate. 


possible,  following  in  disease  the  definite  rules  propounded  by  Jussieu 
for  botany,  we  have  a  guide  that  we  can  follow— the  clinic.  Truly,  if 
lesions  were  always  circumscribed,  and  if  to  such  definite  lesions  a 
particular  group  of  symptoms  always  corresponded,  then  we  should 
have  in  the  anatomical  method  the  most  logical  system  possible ;  but 

1  In  order  to  estimate  tissue  changes  correctly,  we  must  know  the  normal  his- 
tology of  the  part,  and  I  have  therefore  prefixed  to  figures  of  morbid  tissues  one 
which  presents  the  healthy  condition;  this  is  indispensable  for  comparison. 


THE    PATHOLOGY    AND    ETIOLOGY    OF    METEITIS. 


133 


while  this  condition  does  not  exist,  the  anatomical  basis  lacks  all  pre- 
cision and  serves  but  for  illusions. 

I  propose,  therefore,  to  classify  metritis  according  to  the  prevailing 
clinical  symptom  which  may  be  deduced  from  its  course,  or  may 
stand  in  marked  predominance  in  the  order  of  its  symptoms.  We 
have,  accordingly,  the  following  varieties : 

1.  Acute  inflammatory,  ]       These  epithets  shall  have  only  a  taxonomic 

2.  Hemorrhagic,  [  or  classifying  value  henceforth,  and  any  other 

3.  Catarrhal,  '  adjective  will  be  used,  when  necessary,  to 

4.  Chronic  painful.         J  give  them  a  purely  descriptive  force. 


■     g  tr%  ^  jr 


Fig.  91— Normal  Mucous  Membrane  of  the  Cervix,  slightly  Enlarged  (Wyder). 

The  mucous  membrane  of  the  cervix  is  very  firm  and  presents  a  number  of  branching  folds  (arbor 
vitee).  The  interglandular  tissue,  which  has  in  the  body  of  the  organ  the  nature  of  granulation  tissue,  is 
here  of  a  connective-tissue  type,  the  fusiform  and  stellate  cells  predominating.  There  is  not  the  same  clear 
limit  between  membrane  and  muscular  coat ;  and  one  can  follow  the  glands  deeply  inward  among  the  con- 
nective-tissue bands  which  separate  the  muscular  bundles.  Consequently  the  mucous  membrane  in  section 
has  a  partly  reticulated,  partly  fasciculated  appearance.  The  cervical  membrane  possesses,  moreover, 
many  vascular  papillae.  Cylindrical  ciliated  epithelium  invests  the  glands  in  the  adult,  and  in  the  child  ex- 
tends to  the  external  os.  In  the  adult,  especially  after  pregnancy,  the  flat  vaginal  epithelium  rises  higher 
and  lies  more  or  less  within  the  cervix.  Between  the  superficial  cylindrical  epithelium  and  the  glands,  cup- 
shaped  and  colloid  cells  are  here  and  there  present. 

The  vessels  (Moericke)  pass  into  the  mucous  membrane  perpendicularly  and  have  very  thick  walls, 
dividing  progressively  into  a  capillary  plexus,  which  is  less  developed  than  in  the  body.  Sometimes  the 
capillaries  lie  very  superficially  under  the  epithelium,  reuniting  to  form  veins,  which  at  once  leave  the 
mucous  membrane.    The  glands  and  ovula  Nabothi  are  surrounded  by  the  vessels. 

Patliology^ — For  the  methodical  description  of  the  lesions  found 
in  metritis,  it  is  necessary  to  depart  from  the  clinical  arrangement 
and  follow  the  topographical  order,  first  considering  lesions  of  the 
body  and  then  those  of  the  cervix. 

In  most  of  the  treatises  on  metritis  the  division  is  still  main- 
tained of  acute  and  chronic  parenchymatous,  and  internal  (or  mucous, 
i.e.,  endometritis),  and  both  the  pathology  and  clinical  study  of  the 


134 


CLINICAL   AND    OPEKATIVE   GYNAECOLOGY. 


disease  are  arranged  accordingly.  I  have  said  that  I  do  not  adopt  this 
plan  clinically,  but  yet  I  take  advantage  of  it  for  the  study  of  the 
lesions.  As  Sinety5  so  justly  remarks:  "How  shall  we  imagine  that 
the  mucous  membrane  presents  the  lesions  of  an  acute  disease  with- 
out participation  of  the  tissues  below  ?  Or  how  shall  we  suppose  that 
the  glands  are  involved  without  observing  at  the  same  time  that  there 
is  an  alteration  in  their  lymphatic  sheaths  which  communicate  freely 
with  the  lymph-spaces  of  the  parenchyma  ? " 

I  shall  first  describe  the  lesions  of  acute  metritis  throughout  all 
the  uterine  tissues  and  then  those  of  the  chronic  form. 


A/iHANSI** 


Fig.  92.— Section  op  Normal  Uterine  Mugous  Membrane,  from  the  Body  of  the  Organ.  X  200. 
(Cornil.0)  a,  Epithelial  lining  of  the  glands;  b,  layers  of  flattened  cells  in  the  limiting  connective  tissue; 
c,  connective  tissue  with  round  and  ovoid  cells  multiplying;  d,  neighboring  gland,  the  wall  partly  omitted; 
p,P,  folds  in  the  gland  wall  involving  both  connective  tissue  and  epithelium. 


Acute  Metritis. — The  descriptions  which  have  been  given  of  the 
parenchymatous  lesions  of  acute  metritis  all  suffer  from  one  defect: 
non-puerperal  metritis  is  not  fatal  and  does  not  justify  hysterectomy, 
and  hence  descriptions  of  lesions  of  the  uterine  mucous  membrane  and 
parenchyma,  based  on  the  autopsy  of  women  dead  in  the  puerperal 
state,  are  not  comparable  to  those  which  should  be  found  in  acute 
inflammation  of  the  non-gravid  uterus.  We  ought  to  free  our  minds 
of  this  ancient  idea  of  Chomel's,  who  described  all  the  accidents  of 
septicaemia  after  parturition  as  puerperal  metritis.  When  a  woman 
succumbs  to  such  accidents,  there  is  certainly  present  a  septic  inflam- 
mation of  the  entire  uterine  tissue,  but  this  is  merely  an  additional 


THE   PATHOLOGY   AND   ETIOLOGY    OF   METRITIS. 


135 


circumstance  which  defines  the  general  septic  condition  which  proves 
fatal.  It  is  only  then  that  the  pathologist  alone  has  the  right  to 
speak  of  a  septic  puerperal  metritis,  marked  in  life  by  vague  resem- 
blance to  acute  metritis.  This  transposition  of  terms  has  been  so 
often  repeated  since  Aran  that  it  has  become  trite. 

These  authors  note  the  increase  in  volume,  the  softening  of  the 
tissue,  the  red  color  mottled  with  yellow,  the  vascular  dilatation,  and 


0K^'^^f^ 


Fig.  93.— Normal  Mucous  Membrane  of  the  Uterus  during  Menstruation  (Wyder). 
A  preparation  of  the  layer  removed  by  curette  during  menstruation.  The  figure  reproduces  the  upper 
third  of  the  membrane.  There  are  small  extravasations  here  and  there,  in  the  deeper  parts  is  almost 
normal  interglandular  tissue,  the  glands  being  somewhat  more  sinuous  than  usual.  The  blood-vessels 
are  full;  the  upper  layers  are  partly  normal,  partly  infiltrated  with  blood-cells;  the  epithelium,  for  themost 
part  preserved,  is  here  and  there  raised  from  its  seat  and  covered  with  altered  blood-cells;  hemorrhage 
into  the  glands  in  places;  no  appearance  anywhere  of  the  fatty  degeneration  described  by  certain  authors 
(.Williams,  Kundrat,  Engelmann).  It  is  very  likely  that  sometimes  during  menstruation  part  of  the  mu- 
cous membrane  is  destroyed  QLeopold,  Wyder),  and  that  there  is  no  such  desquamation  at  other  times 
(Moericke).  This  figure  shows  that  the  different  changes  maybe  simultaneous,  and  that  there  is  great 
diversity  in  the  process. 

the  shedding  of  the  mucous  membrane.  Finally,  to  complete  the 
cycle  of  acute  inflammation  with  pus-formation,  most  authors  blindly 
repeat  a  number  of  ancient  observations  which  are  all  exposed  to 
hostile  criticism.  Their  x>retended  uterine  abscesses  are  either  collec- 
tions of  pus  in  the  neighborhood,  as  in  pyo-salpinx,  or  suppuration  in 
a  degenerated  myoma,  neither  of  which  bear  any  relation  to  metritis. 


136 


CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 


Of  the  two  cases  reported  by  Schroder,  one,  post  partum,  seems  to  be 
a  simple  parametritis  ■  the  other,  opened  by  the  rectum  after  uterine 


CZdtia  cel/ularum 


Jj-Zoxa  exfohalionts, 


£  Zona  g&ndu!arum..>y 


Fig.  94. — Normal  Placenta  (Friedlaender,  Wyder). 

The  figure  is  largely  diagrammatic,  for  the  sake  of  clearness.  It  represents  the  placenta  at  the  end  of 
pregnancy.  This  membrane  is  the  product  of  two  factors,  viz.,  proliferation  of  the  uterine  mucous  mem- 
brane in  all  its  elements,  and  compression  of  this  hypertrophied  mass  by  the  enlarging  ovum.  There  are 
thus  two  layers,  the  cellular  (zona  cellularum)  and  the  glandular  (zona  glandularum).  The  former  lies 
close  to  the  foetal  membranes  (amnion  and  chorion),  and  is  made  up  of  cells  which  measure  2  /u.  to  61  ^  in 
diameter;  superiorly  they  are  round,  but  below  they  become  fusiform.  Intercellular  tissue  is  altogether 
lacking,  or  present  as  a  trace  merely.  The  glandular  layer  shows  a  plexus  of  flattened  alveoli,  not  very  long 
or  wide,  not  communicating  with  each  other  freely,  empty  or  filled  with  granular  matter.  The  layers  which 
separate  these  alveoli  are  formed  of  connective  tissue,  richly  supplied  with  vessel's  and  infiltrated  with 
lymph  cells.  They  are  covered  on  the  internal  surface  by  epithelium;  in  places  pavement,  in  others 
cylindrical. 

The  zona  exfoliationis,  or  separating  line  between  the  two  layers,  is  produced  almost  always  in  the 
cellular  layer  (Friedlander)  and  but  seldom  in  the  glandular;  the  opposite  is  the  case  according  to  Lang- 
haus,  Hiistner,  and  Leopold.  The  above  figure,  after  Friedlander,  is  modified  according  to  the  views  of 
his  opponents,  who  seem  to  be  correct  (Wyder).  The  glandular  cavities  thus  opened  by  placental  separa- 
tion furnish  thr  regenerated  epithelium  of  gland  and  mucous  membrane  after  parturition. 

sounding,  was  probably  suppuration  of  the  tubes.  This  latter  explan- 
ation must  be  given  also  to  the  case  of  Hervey  de  Chegoin,7  so  often 
cited 


THE    PATHOLOGY    A^D    ETIOLOGY    OF    METRITIS. 


137 


A.  Martin 8  has  related  a  case  which  was  suppuration  of  a  myoma 
but  which  exactly  simulated  uterine  abscess.  J.  B.  Kirkpatrick 9  has 
lately  published  a  case  under  the  name  of  uterine  abscess  where  the 
cavity  of  Retzius  was  invaded  and  the  pus  appeared  at  the  umbilicus 
— probably  a  parametritis. 

Surely,  if  one  would  assert  that  suppuration  of  the  uterine  wall  is 
possible,  we  should  agree  with  him ;  but  that  it  occurs  as  part  of  the 
clinical  picture  we  call  metritis — that  we  deny. 

Our  most  trustworthy  source  of  information  as  to  the  acute  lesions 
of  the  mucous  membrane  is  found  in  examination  of  the  membrane 


5,.-VS«'6'V"/-'b 


■S  '■/yy/  ''■>  sr/yfflr' 


Fig.  95.— Acute  Septic  Metritis.    Slightly  enlarged  view  of  entire  uterine  -wall,    a,  b,  Surface  of 
mucous  membrane;  below  are  seen  sections  of  muscular  bundles. 


of  membranous  dysmenorrhcea.  The  mucous  membrane  is  abnormal 
both  in  softness  and  thickness ;  the  microscope  shows  no  change  in 
the  glands  but  a  peculiar  alteration  in  the  interglandular  tissue ;  the 
cells  being  far  more  numerous  than  usual  and  so  tightly  packed 
against  each  other  that  there  is  almost  none  of  the  homogeneous 
intercellular  substance  left.  They  preserve  their  normal  volume  and 
differ  in  that  respect,  and  in  the  small  amount  of  their  protoplasm, 
from  the  cells  of  the  placenta.  In  other  words,  we  have  to  do  (Fig. 
96)  with  an  acute  interstitial  inflammation.10 

Chronic  Metritis. — The  parenchymatous  lesions  of  chronic  metri- 
tis are  particularly  characterized  by  a  hypertrophy  of  the  connective 


138 


CLINICAL   AND    OPERATIVE    GYNECOLOGY. 


tissue,  causing  a  general  enlargement  of  the  organ,  which,  however, 
does  not  exceed  the  size  of  a  fist.  This  increase  in  volume  may  be 
absent  altogether,  and  then  we  have  a  decrease  in  the  size  of  the 
organ.  Theoretically  there  are  two  stages,  according  to  Scanzoni:  n  the 
one  of  infiltration  and  the  other  of  induration.  The  first  of  these  cor- 
responds to  an  active  or  passive  congestion  of  the  uterus,  where  the 
vessels  are  so  dilated  that  the  wall  of  the  organ  has  an  almost  areolar 
aspect.  There  are  great  numbers  of  embryonal  nuclei  throughout  the 
thickness  of  the  tissue.     The  predominating  change  is  hypertrophy 


Fig.  96.— Acute  Endometritis,  Membranous  Dysmenorrhea  (Wyder).    Strongly  magnified. 

of  the  connective  tissue,  but  authors  are  not  agreed  as  to  the  partici- 
pation of  the  muscular  tissue  in  this  hypertrophy.  Finn, 12  of  St. 
Petersburg,  admits  the  hypertrophy  but  denies  the  importance  of  the 
fatty  degeneration  described  by  others.  De  Sinety  has  discovered  in 
one  case  a  considerable  dilation  of  the  normal  lymph  spaces,  and 
hyperplasia  of  the  perivascular  connective  tissue  which  diminishes 
the  calibre  of  the  vessels  and  gives  rise  to  a  special  form  of  sclerosis. 
The  muscular  tissue  does  not  seem  to  be  involved. 

When  the  uterine  parenchyma  has  thus  been  the  seat  of  profound 
and  lasting  inflammatory  processes,  it  is  unusual  not  to  have  with  it 
evidences  of  perimetritis,  adhesions  in  Douglas'  pouch  with  displace- 


THE    PATHOLOGY    AND    ETIOLOGY    OF   METRITIS. 


139 


ment  of  the  organ,  and  traces  of  salpingitis  and  inflammation  about 
the  tubes  and  ovaries.  The  uterine  mucous  membrane  in  always  in- 
volved to  a  greater  or  less  extent. 

In  many  cases  of  endometritis  of  the  uterus  and  the  cervix,  in- 
dependent of  parturition  or  occurring  in  aged  women  who  have  had 
children  long  before,  Cornil 13  has  found  hypertrophy  of  the  uterine 
wall  due  entirely  to  a  new  formation  of  adult  connective  tissue  be- 
tween the  muscular  trabeculse.  To  the  naked  eye,  the  muscular  tis- 
sue is  then  of  a  pale  red  color,  presenting  a  series  of  opaque  lines 
which  are  thickened  and  sclerotic  arterioles  in  a  state  of  atheromatous 


Fig.  97. — Chronic  Metritis,    a,  a,  Muscular  tissue  traversed  by  bands  of  smooth  connective  tissue; 
6,  b,  connective  tissue;  c,  c,  vessels  with  thickened  walls;  d,  lymph  space. 


degeneration.  Under  the  microscope  this  thickening  of  the  vessel - 
wall  is  found  to  be  considerable,  the  elastic  elements  are  increased 
and  present  also  numerous  cells  in  fatty  degeneration.  The  con- 
nective-tissue sclerosis  corresponds  to  that  of  the  arterial  and  venous 
coats,  and  is  not  so  much  a  cicatricial  contraction  of  the  connective 
tissue  as  a  permanent  augmentation  of  its  volume.  The  microscopic 
and  histological  lesions  of  the  mucous  membrane  under  chronic  in- 
flammation are  to-day  perfectly  understood,  thanks  to  the  opera- 
tions which  permit  the  study  of  so  many  fresh  specimens  of  this  dis- 
order. 

I  cannot  better  describe  the  usual  apjDearance  of  a  uterine  mucous 


140  CLINICAL   AID    OPERATIVE    GYNAECOLOGY. 

membrane  thus  altered,  than  by  reproducing  the  words  of  Cornil  in 
his  recently  published  "Lecons;"14  his  description  applies  especially 
to  chronic  glandular  endometritis,  the  more  common  form: 

"  The  mucous  membrane  does  not  present  its  normal  whitish  color, 
smooth  surface,  and  peculiar  rigidity ;  it  is  bloated,  pulpy,  soft,  and 
both  in  aspect  and  consistence  resembles  currant  jelly;  the  discolora- 
tion is,  in  places,  very  marked  and  may  have  the  appearance  of  a  layer 
of  blood  interspersed  with  dark  clots.  This  softened  layer,  formed 
by  the  inflamed  mucous  membrane,  is  easily  displaced  by  the  scalpel, 
readily  elevated  or  torn  by  gentle  traction.  There  is  present  an  in- 
tense congestion  throughout  the  organ,  between  the  muscular  fibres, 
but  this  is  most  pronounced  on  the  deep  surface  of  the  mucous  mem- 
brane. On  a  section  of  the  organ,  if  made  with  a  very  sharp  knife,  it 
is  difficult  to  distinguish  muscle  from  mucous  membrane,  the  two 
having  a  similar  appearance.  However,  the  mucous  membrane  is 
easily  scraped  off  with  the  curette  which  cannot  penetrate  the  mus- 
cular layer  unless  it  is  much  softened  by  inflammation,  which  is 
very  unusual. 

Hardened  in  alcohol,  to  fix  the  different  elements,  and  cut  in 
microscopic  section,  it  is  easily  seen  that  the  mucous  layer  is  abnor- 
mally thick.  When  stained  by  picro-carmine  this  thickening  is  very 
plain  to  the  naked  eye.  The  mucous  membrane  then  has  a  slightly- 
yellow  tinge,  which  distinguishes  it  from  the  redder  muscular  tissue. 
It  is,  moreover,  more  transparent,  especially  in  its  deeper  portions, 
where  the  microscope  reveals  the  presence  of  glands.  To  appreciate 
these  details  by  the  naked  eye  it  is  enough  to  examine  a  section 
stained  by  picro-carmine,  holding  it  against  the  light;  the  mucous 
membrane  is  seen  to  be  2  to  5  mm.,  even  1  cm.  thick  at  times,  whereas 
its  usual  thickness  is  but  1  mm.  Its  surface,  instead  of  being  smooth, 
is  fungous,  presenting  alternate  projections  and  depressions  of  a 
flabby  appearance.  These  fungosities  have  received  the  name  of  villi, 
vegetations,  etc.,  and  the  disease  has  been  therefore  termed  villous, 
fungous,  granulating,  or  vegetating  metritis.  These  vegetations  are  at 
times  very  large,  of  a  round  and  elongated  form,  and  may  become 
veritable  polypi,  sessile  or  pedicled.  In  other  cases  there  are  small 
cysts,  of  the  size  of  a  pin's  head,  resembling  the  ovules  of  Naboth,  so 
common  in  the  cervix  and  about  the  os  externum,  and  having  the 
same  glandular  origin ;  but  they  differ  from  these  in  the  quality  of 
the  fluid  contained.  It  is  more  thin  and  serous,  less  consistent  and 
colloid,  than  the  contents  of  the  Nabothian  ovules  of  the  cervix. 


THE   PATHOLOGY    AND    ETIOLOGY    OF    METRITIS. 


141 


These  small  cysts  of  the  body  of  the  uterus  are  seen  more  often  in 
aged  patients  than  in  the  young. 

"  Such  is  the  macroscopic  appearance  of  the  uterine  mucous  mem- 
brane after  chronic  inflammation."  6 

In  the  histology  of  the  subject  there  are  three  distinct  types,  often 
clearly  presented  in  different  subjects  or  at  times  combined  in  one. 
In  this  description  I  follow  Wyder's  recent  work.15 

Chronic  Interstitial  Endometritis. — The  interglandular  tissue 
which  we  have  seen  gorged  with  cells  in  the  acute  form  so  that  it 


Fig.  98.— Interstitial  Endometritis  ■with  Partial  Atrophy  op  the  Glands  (Wyder). 

resembles  granulation  tissue,  is  transformed  into  true  cicatricial  tissue 
in  which  the  number  of  cellular  elements  steadily  increases.  The 
glands  undergo  the  opposite  alteration,  being  strangled  in  places  and 
transformed  into  cysts,  or  so  compressed  in  their  whole  extent  that 
they  atrophy,  and  thus  we  may  have  a  few  glands  scattered  through 
the  connective  tissue  (Fig.  98),  altered  into  cysts  in  places  (Fig.  99, 
A)  or  totally  destroyed  (Fig.  99,  B). 

In  cases  where  the  atrophy  is  very  marked  the  muscular  layer  is 
covered  by  only  a  very  thin  layer  of  sclerosed  connective  tissue  and 
this  in  turn  by  epithelium.  Under  the  surface  still  covered  by  pave- 
ment epithelium  (Fig.  98),  one  sees  the  mucous  membrane  traversed 


142 


CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 


by  these  fibrous  layers  wliicli  frequently  interlace  to  form  a  mesh- 
work,  generally  filled  with  a  homogeneous  substance,  though  the 
deeper  portion  of  the  tissue  may  be  full  of  round  cells  packed 
close  together.  Nearer  the  surface  the  interglandular  tissue  has  a 
more  regular  arrangement,  being  composed  of  a  series  of  layers  of  cells 
and  their  parallel  prolongations.  The  section  may  contain  only  very 
few  glands. 

At  many  points   (Fig.  99)  there  are   cystic   cavities,   lined  with 


Fig.  99. — Interstitial  Endometritis  with  Complete  Atrophy  of  the  Glands  (Wyder).    A,  Cystic 
formation,  last  trace  of  glands;  B,  all  vestige  of  gland  tissue  disappeared. 


cuboidal  epithelium  and  surrounded  by  bands  of  connective,  tissue 
with  fusiform  cells.  At  places  there  are  evidently  no  glands  present, 
aud  the  mucous  membrane  is  represented  by  a  homogeneous  connective 
tissue  which  possesses  no  cells  and  is  arranged  in  many  bundles,  the 
whole  being  clearly  marked  off  by  a  sharp  line  from  the  muscular 
tissue.  Near  the  surface  this  formation  is  smooth  in  places  and  at 
others  arranged  in  large  flat  villous  projections.  There  are  present, 
therefore,  all  the  signs  of  advanced  connective-tissue  sclerosis. 

Chronic  Glandular  Metritis. — Ruge,  and  after  him  Wyder,  rec 
ognized  two  forms  of  glandular  endometritis,  the  hypertrophic  and 


THE    PATHOLOGY   AND    ETIOLOGY    OF    METRITIS.  143 

the  hyperplastic.  In  the  first,  the  epithelial  proliferation  takes  place 
without  multiplication  of  the  glands  themselves.  Instead  of  being  a 
series  of  straight  tubes,  the  glands  are  then  of  irregular  form,  fre- 
quently twisted  and  arranged  spirally.  In  the  hyperplastic  form  there 
is  an  increase  in  the  number  of  the  glands.  Cornil 16  has  discovered 
karyokinetic  figures  in  the  epithelium  lining  the  glands  (Fig.  102)  in 
such  cases.  He  is  of  opinion  that  this  may  be  normally  present  after 
menstruation,  as  it  is  a  feature  of  physiological  repair  in  gland  cells. 


V-i. 


Fig.  100.— Glandular  Endometritis  op  the  Uterine  Body  I  Wyder).    Slightly  enlarged. 

Figure  100  presents  a  form  of  combined  hypertrophy  and  hyper- 
plasia which  is  more  common  than  is  usually  supposed.  The  gland- 
ular tissue  is  absolutely  normal  in  structure,  but  the  glands  them- 
selves are  much  distorted  and  have  lateral  prolongations. 

Chronic  Polypoid  Endometritis. — This  form  is  marked  by  an 
enormous  development  of  the  mucous  membrane,  which  has  a  fungous 
appearance  and  may  be  bristling  with  small  and  soft  polypi.  Reca- 
mier  "  was  the  first  to  give  a  good  description  of  the  macroscopic  ap- 
pearance in  this  form,  and  Olshausen  has  lately  studied  the  subject 
anew.  It  is  a  mixture,  histologically,  of  interstitial  and  glandular 
changes  with  marked  cystic  degeneration.  On  the  surface  the  naked 
eye  discovers  small  vesicles  of  1  mm.  diameter,  transparent  and  a  little 


144 


CLINICAL   AND   OPERATIVE   GYNECOLOGY. 


elevated;  and  these  under  the  microscope  (Fig.  101)  are  plainly  degen- 
erated glands  lined  with  cuboidal  epithelium.  They  are  separated  by 
bands  of  connective  tissue;  in  the  superficial  layers  the  glands  are 


Fig.  101.— Glandular  Endometritis,  Polypoid  Form  (Wyder). 

widely  dilated,  and  more  deeply  they  appear  normal  but  are  bent 
aside,  parallel  or  oblique  to  the  muscular  fibres. 

The  glandular  culs-de-sac  pass  beyond  their  usual  limit  in  the 
depth  of  the  mucous  membrane  and  sink  in  between  the  subjacent 


£ 


.-t 


no    ) 


*TL- 


Fig.  102.— Epithelial  Investment  op  a  Gland  from  the  Body  op  the  Uterus  (Cornil).  X  350. 
Reichert's  apochromat.  with  00.4.  I,  Nucleus  with  enlarging  granules  and  filaments  of  nuclein;  k,  nucleus 
showing  the  beginning  karyokinesis,  with  "star11  arrangement  of  nuclein;  m,  small,  round  wandering 
cell  between  the  cylindrical  cells. 

muscular  fibres  according  to  Cornil  (Fig.  103).  This  is  a  remarkable 
instance  of  what  the  older  anatomists  called  "  glandular  heterotopy  " 
occurring  with  a  simple  inflammation  having  no  tendency  to  become 
malignant.     In  this  invasion  of  the  muscular  tissue  a  certain  amount 


THE    PATHOLOGY   AND    ETIOLOGY    OF    METRITIS.  145 

of  their  investing   connective  tissue  accompanies   the  glands.     The 
interglandnlar  structure  is  very  rich  in  vessels. 

At  the  points  which  correspond  to  glandular  dilatations,  there  are 

fes  ...... 


?i'H''?. 


Q 


?., 


41 


life        ■'■  ■ *;-       '■■■■'■  '  *:- 


Fig.  103.— Glandular  Endometritis  (Coknil).  x  40.  Section  showing  the  deep  penetration  of  the 
gland,  a,  Surface  of  mucous  membrane,  epithelium  partly  removed ;  b.  gland  opening  on  the  surface; 
fir,  glandular  cul-de-sac  deeply  placed;  t,  connective  tissue,  new  formed,  with  many  lymph  cells;  ft,  ft, 
glands  divided  lengthwise,  twisted,  and  dilated  in  places;  m,  muscular  bundles  between  which  the  termina- 
tion of  the  glands  are  seen. 

inclosed  numbers  of  spindle-shaped  cells,  whose  prolongations  give 
the  part  a  striated  appearance,  or,  at  other  times,  the  tissue  has  very 
few  cellular  elements;  this  latter  arrangement  is  especially  noticed 


146  CLINICAL   AND   OPERATIVE   GYNECOLOGY. 

about  the  blood- vessels.  Lying  deeply  about  the  intact  glands  among 
the  cysts  there  is  found  a  homogeneous  substance,  replacing  the 
proper  interglandular  tissue,  which  is  "full  of  round  cells  pressed 
closely  together  (Fig.  101).  De  Sinety 18  has  given  an  excellent  de- 
scription of  the  lesions  of  endometritis,  although  a  post-mortem  exam- 
ination was  made  on  but  one  case.  He  specially  studied  the  vegeta- 
tions and  excrescences  which  are  to  be  observed  upon  the  mucous 
membrane,  and  which  he  removed  for  the  purpose  by  a  Recamier's 
curette ;  but  he  laid  less  emphasis  upon  alterations  in  the  membrane 
itself.  He  describes  three  kinds  of  vegetation :  the  glandular,  formed 
by  enlarged  and  distorted  glands,  with  thickening  of  the  connective 
tissue ;  the  embryonal,  formed  of  embryonic  tissue  and  a  few  dilated 
vessels;  and  the  vascular,  composed  of  vessels  often  widely  dilated. 

Certain  authors  discuss  a  diphtheritic  metritis,  which  it  were 
better  to  call  gangrenous,  since  the  false  membrane  is  merely  the 
product  of  a  partial  mortification.  This  is  a  simple  nosological  error 
which  has  crept  into  the  group,  so  well-defined  clinically,  of  inflam- 
mations of  the  uterus ;  whereas  it  is  but  a  simple  accident  which  may 
happen  in  the  uterus  or  elsewhere, "  in  certain  peculiar  conditions 
either  general  or  local.  Thus,  diphtheritic  metritis  has  been  seen  to 
follow  tamponade  with  perchloride  of  iron.19  and  to  occur  after  enu- 
cleation of  a  fibroma,  or  in  the  course  of  a  septicaemia  in  an  old  woman 
who  had  a  phlegmon  upon  the  lower  extremity.20  Cornil  has  also 
observed  certain  details  of  high  interest  where  the  only  change  visible 
is  extreme  enlargement,  and  the  glands  in  longitudinal  or  cross  section 
present  a  single  flat  layer  of  cylindrical  cells,  usually  on  their  internal 
aspect.  Where  there  are  many  layers  superimposed,  the  details  are 
difficult  to  grasp,  but  sections  sufficiently  thin,  if  well  examined,  dis- 
close only  a  single  series  of  cells.  The  vibratile  cilia  which  are  found 
upon  normal  glandular  epithelium  are  in  great  part  preserved,  and 
this  retention  of  cilia  in  a  gland  so  modified  by  chronic  inflammation 
is  a  remarkable  fact.  At  the  same  time,  it  is  not  always  easy  to  find 
these  cilia ;  it  is  necessary  to  use  for  that  purpose  excellent  objectives 
and  tissue  absolutely  fresh.  To  demonstrate  them  the  material  must 
be  taken  as  it  comes  from  the  surgeon's  hands  at  the  operation  and 
placed  directly  in  some  hardening  fluid,  preferably  90$  alcohol.  In 
preparations  even  of  irreproachable  freshness  the  cilia  may  seem  to 
have  disappeared ;  then  there  is  seen  upon  the  surface  of  the  cell  a 
delicate  layer  of  mucus,  sometimes  clear  and  homogeneous,  at  others 
as  if  formed  of  little  spheroid  bodies,  or  somewhat  striated,  composed 


THE    PATHOLOGY    AND    ETIOLOGY    OF    METRITIS. 


147 


of  an  agglomeration  of  the  cilia.  The  cells  which  fill  the  alveoli,  often 
completely,  are  identical  with  those  found  normally  in  the  nterine 
glands,  cylindrical  or  modified,  ovoid  or  even  mncons. 

The  only  difference  presented  by  portions  of  tissue  scraped  off  with 
the  curette  and  entire  sections  of  the  uterus,  is  found  in  the  difficulty 
of  recognizing  the  relations  of  the  first ;  and  therefore  it  is  better  to 
study  sections  made  perpendicularly  to  the  surface  in  material  pro- 
vided by  hysterectomy. 

Finally,  there  is  a  histological  variety  of  endometritis  which  does 
not  deserve  the  dignity  of  being  placed  in  a  separate  class,  and  yet 
should  be  mentioned,  and  that  is  post-abortum  endometritis.  Ac- 
cording to  Schroder 21  it  is  almost  always  an  interstitial  form  of  metri- 


lISp 


Fig.  104. — Endometritis  Post  Abortum,  showing  Islands  of  Decidua  about  which  is  an  Active 

Proliferation  of  Cells. 


tis  which  occurs  after  abortion,  the  glands  taking  part  only  very  late 
in  the  disease.  But  the  feature  which  distinguishes  such  metritis  ana- 
tomically is  the  persistence  of  the  decidua  (vera  or  serotina)  which 
undergoes  a  partial  retrograde  metamorphosis ;  if  this  persistence  is 
partial,  we  find  little  islands  of  decidua,  more  or  less  prominent, 
about  which  there  is  a  very  active  proliferation  of  small  cells  (Fig. 
104).  This  inflammatory  modification  of  the  mucous  membrane,  adds 
Schroder,  differs  essentially  from  retention  of  the  placenta,  which  is 
often  described  under  the  inappropriate  name  of  endometritis  post 
abortum,  and  which  is  only  a  hemorrhage  post  abortum  due  to  incom- 
plete contraction  of  the  uterus  and  its  vessels. 

Lesions  of  tlie  Cervix.— Anatomically  it  is  incorrect  to  speak  of 
metritis  of  the  body  as  distinct  from  metritis  of  the  cervix,  for  these 


148 


CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 


two  portions  of  the  uterus  are  never  completely  independent ;  most 
frequently  the  lesions  are  synchronous  and  undergo  a  parallel  evolu- 
tion. However,  there  is  often  a  more  decided  localization  of  the  dis- 
ease in  one  or  the  other  of  these  different  parts ;  and  as  the  cervix  is 
the  more  exposed  to  traumatism,  cervical  metritis  predominates.  If 
the  mucous  membrane  of  the  cervix  is  thoroughly  diseased,  the  pro- 
cess is  carried  step  by  step  into  the  fibrous  and  muscular  portions,  and 
thus  a  veritable  parenchymatous  metritis  occurs  with  every  inflam- 


?■  '-W  mJ$W)\MMsmg% 


Fig.  105.— a,  6,  Simple  papillary  erosion ;  c,  follicular.    Slightly  enlarged. 


mation  of  the  cervix  if  of  long  duration.  Cornil  expressly  describes 
a  parenchymatous  metritis  which  may  be  partial.  For  example,  the 
lesions  are  at  times  restricted  to  the  cervix  in  the  ectropion  of  the 
part  caused  both  by  thickening  of  the  mucous  membrane,  turned 
outward  into  the  vagina,  and  by  thickening  of  the  connective  tissue 
beneath  the  mucous  membrane  and  between  the  muscular  fibres.  In 
this  connective  tissue  lesions  of  recent  inflammation  can  often  be 
demonstrated,  by  thickness  of  the  trabecular  and  of  the  interposed  flat 
cells.22 

The  neck  of  the  uterus  may  present  special  and  very  diverse  lesions 


THE    PATHOLOGY    AISLD    ETIOLOGY    OF   METRITIS. 


149 


in  metritis ;  there  may  be  lacerations,  ectropion,  hypertrophy,  conges- 
tion, varix,  granulations,  folliculitis,  erosions,  ulcerations,  cysts,  and 
ovules  of  Naboth,  etc.,  etc.     When  this  part  of  the  uterus  is  accessible 


x  m3 


to  the  view,  the  macroscopic  description  should  enter  into  the  clinical 
demonstration ;  but  it  is  necessary  also  to  make  the  exact  nature  of 
the  disease  clear  by  the  resources  of  histology. 

Ovules  of  JVabotJi,  Granulations,  Folliculitis. — The  ISTabothian 


150 


CLINICAL   AND    OPERATIVE    GYNAECOLOGY. 


glands,  so  called,  are  small  cysts;  granulations  and  folliculitis  are 
small  ulcerations  (I  will  explain  the  value  of  the  word  farther  on), 
scattered  over  the  surface  of  the  uterine  neck.  The  one  or  the  other 
of  these  resemble  an  eruption,  and  authors  have  been  led  to  identify 
them  with  those  of  the  external  integument,  erythema,  eczema, 
herpes,  acne,  pemphigus,23  etc.,  but  the  parallel  is  purely  arbitrary, 
built  upon  theoretical  views  and  lacking  all  serious  foundation. 

Erosions,  Ulcerations. — The  cervix  may  present,  near  the  external 
os,  a  red  and  rough  aspect  without  protuberances  or  depressions ;  this 
is  erosion,  properly  so  termed.     It  may  be  observed  in  acute  vaginitis 


Fig.  107.— Section  of  the  Mucous  Membrane  of  the  Vaginal  Portion  in  a  Case  of  Chronic  In- 
flammation (Cornil).  X  40  diara.  e,  Papillae  covered  with  a  single  layer  of  cylindrical  epithelium;  c, 
epithelium  begins  to  be  squamous;  d,  thickening  of  the  squamous  epithelium;  s,  superficial  corneous  layer; 
to,  mucous  membrane  much  thickened;  p,  papillae;  t,  t,  connective  tissue;  v,  vessels 


with  abundant  secretion,  or  after  contact  with  a  foreign  body  (pes- 
saries) ;  under  the  microscope  it  is  seen  that  there  is  a  simple  substi- 
tution of  flat  normal  vaginal  epithelium  for  the  proper  cylindrical. 
Fischel 24  has  shown  that  there  is  often,  in  the  infant  at  birth,  a  pseudo- 
erosion  of  the  external  os,  the  epithelium  being  then  cylindrical  over 
a  certain  zone  externally.  Later  on,  this  epithelium  is  invested  by 
stratified  pavement  cells ;  but  when  these  desquamate,  the  original 
appearance  is  restored.  Should  there  thus  be  a  congenital  predis- 
position to  erosions  it  would  be  a  curious  fact.  The  observations  of 
Klotz25  seem  to  favor  this  view.  According  to  him  there  are  patients 
who  suffer  from  erosion  or   ulceration  under  the  influence  of  the 


THE   PATHOLOGY   AND    ETIOLOGY    OE   METRITIS. 


151 


lightest  inflammation,  wliile  others,  though  there  be  a  severe  cervical 
catarrh,  never  present  such  changes. 

This  author,  moreover,  insists  on  the  anatomical  differences  of  the 
individual  as  regards  the  adult  and  the  virginal  conditions  of  the 
cervix  and  the  line  of  demarcation  between  the  two  kinds  of  epithe- 
lium. It  would  seem,  then,  that  certain  women  are  especially  exposed, 
by  a  congenital  idiosyncrasy,  to  cervical  metritis. 

Ulceration  [erosion]  is  a  term  applied  to  still  another  kind  of  ap- 
pearance :  namely,  where  the  entire  circumference  of  the  os,  or  only  a 
part  of  it,  seems  to  be  depressed  over  a  circumscribed  area,  presenting 
a  circular  edge  and  a  smooth,  red  surface  or  one  covered  with  villi. 
Gynaecologists  have  always  regarded  this  condition  as    an   actual 


Fig.  108. — A  Portion  op  the  Mucous  Membrane  of  the  Previous  Figure  more  Highly  Magnified 
(Cornil).  X  200diam.  a,  Thickness  of  the  superficial  epithelial  layer,  formed  of  cylindrical  cells  much 
elongated;  e,  interpapillary  depression;  t,  connective  tissue. 


loss  of  substance  with  destruction  of  the  tissue,  giving  it  the  name 
of  ulceration  of  the  cervix,  and  some  of  them  singularly  mag- 
nify its  importance.  Lisfranc  made  this  the  capital  symptom  of 
his  "uterine  engorgement;"  for  him,  it  was  the  principal  disease. 
Then  followed  a  reaction,  and  Gosselin  26  had  the  courage — great  for 
the  period  when  he  formulated  the  opinion — to  assert  that  ulceration 
was  not  at  all  a  disease,  but  merely  the  symptom  of  the  uterine  catarrh 
which  Melier's 27  work  had  made  known  to  the  profession.  It  is  not  as 
an  inflammatory  lesion,  he  declared,  which  reacts  upon  the  system 
(Recamier's  and  Lisfranc's  opinion),  that  ulceration  is  serious  in  its 
effects,  but  solely  by  the  enfeebling  drain  of  the  discharge. 

Tyler  Smith,28  and  more  recently  Roser,29  see  in  this  lesion  only  a 
kind  of  hernia  of  the  mucous  membrane  within  the  cervix,  which  is 


152 


CLINICAL   AND    OPERATIVE    GYNAECOLOGY. 


comparable,  according  to  Roser,  with  the  similar  condition  observed 
in  the  lids  during  conjunctivitis.  This  anthor  distinguishes  a  trau- 
matic or  cicatricial  ectropion,  due  to  laceration  of  the  cervix,  and  an 
inflammatory,  due  to  hernia  of  the  mucous  membrane.  Assuredly  a 
certain  portion  of  the  intra-cervical  mucous  membrane  does  make 
such  a  descent  when  it  is  swollen  so  that  it  passes  out  of  the  external 
os  and  appears  upon  the  external  surface  of  the  part.  It  would  thus 
form  the  greater  portion  of  the  exposed  ulcerated  surface  in  deep 
laceration.  But  in  the  majority  of  cases  the  external  os  is  closed  and 
does  not  allow  more  than  a  very  thin  edge  of  the  internal  mucous 


Fig.  109.— Follicular  Hypertrophy  of  the  Cervix,    a,  Anterior  lip,  internal  surface  displayed  by 
an  incision;  fc,  same,  anterior  lip,  front  view. 

membrane  to  protrude,  and  when  the  ulceration  has  invaded  a  large 
part  of  the  convexity  of  the  cervix  we  absolutely  must  recognize  that 
the  ulceration  has  taken  place  in  situ,  upon  that  particular  surface. 

What  is  the  exact  nature  of  the  alteration  ?  Does  the  ancient 
notion  of  ulceration  correspond  exactly  to  an  anatomical  reality  or 
only  to  an  appearance  ?  The  authoritative  work  of  Ruge  and  Veit, 
verified  in  France  by  De  Sinety,  clears  up  this  question.  These  authors 
affirm  that  there  is  no  destruction  of  tissue,  but  a  new  formation; 
that  while  the  cylindrical  epithelium  replaces,  at  the  level  of  the  ex- 
ternal ulcerated  surface,  the  pavement  epithelium,  it  is  the  product  of 
the  adjacent  glands,  and  the  interglandular  substance  between  the 
depressions  assumes  the  appearance  of  stakes  in  a  palisade,  whence 
the  papillary  aspect  of  the  surface.     So  that  when  a  bilateral  lacera- 


THE    PATHOLOGY    AND    ETIOLOGY    OF    METRITIS. 


153 


tion  permits,  by  this  new  glandular  formation,  a  large  display  exter- 
nally, the  mucosa  projects  like  a  lining  of  crimson  velvet  in  a  sleeve. 
It  is  certain  that  laceration  forms  ulceration,  but  it  is  exaggeration 
to  say,  with  Bouilly,30  that  there  is  no  true  ulceration  without  lacera- 
tion due  to  child-birth.  At  other  times  the  glands  become  cystic 
and  form  little  projections  on  the  bottom  of  the  ulcerated  [eroded] 
surface,  which  thus  has  the  so-called  follicular  appearance  (more 
evident  in  section  than  to  direct  inspection31)  (Fig.  105,  c).  These 
cysts  may  form  a  semi-detached  mass  on  the  surface  of  the  part,  as 
mucous  polypi  (Fig.  110).   They  are  small,  of  a  red  color,  semi-trans- 


Fig.  110.— Mucous  Polypi  from  the  Interior  of  the  Cervix, and  upon  the  Surface,  from 
Follicular  Hypertrophy 


parent  or  purplish,  hanging  by  pedicles  more  or  less  free  in  the  cav- 
ity, and  projecting  from  the  external  os;  in  general  resembling  the 
mucous  polypi  of  the  nose,  only  far  more  vascular.  (It  is  a  mistake 
to  describe  mucous  polypi  of  the  uterus  in  a  separate  chapter,  since 
pathologically,  clinically,  and  therapeutically,  they  belong  to  hem- 
orrhagic metritis.32)  When  this  cystic  transformation  of  the  glands 
takes  place  throughout  the  cervix,  it  can  produce,  by  penetrating 
and  dilating  its  substance,  an  elongation  by  follicular  hypertrophy 
(Fig.  109,  a).  Finally,  the  glandular  vegetation  and  the  cystic  for- 
mation may  produce  within  the  cavity  of  a  partly-opened  cervix  small 
vesicular  projections  whijh  I  compare  to  an  almond  (Fig.  109,  b).  The 


154 


CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 


theory  of  Huge  and  Veit,  true  in  most  of  these  cases,  is  not,  how- 
ever, so  absolute  as  its  authors  have  declared.  Fischel  has  objected 
to  their  exclusiveness  and  shown  that  there  is  at  times  an  actual 
loss  of  substance,  an  ulceration  in  the  proper  sense  of  the  word. 

The  epithelium  in  such  cases  is  desquamated,  and  the  mucous 
membrane  is  renewed  by  inflammatory  granulations  which  start  from 
the  papilla?.  Doderlein 33  has  verified  the  reality  of  these  two  pro- 
cesses, that  of  pseudo-ulceration  (Huge  and  Veit),  and  that  of  the  real 
form  (Fischel). 


!*£  »&r>=i*a<S'.->^s-S 


Fig.  111. — Section  of  a  Glandular  Uterine  Polypus  (Cornil).  X  60diam.  a,  a,  Superficial  nodules 
covered  with  cylindrical  epithelium;  b,  mouth  of  glands  opening  into  depression  between;  g,  deeper  por- 
tions of  the  same  glands;  v,  v,  blood-vessels. 

Laceration  of  the  cervix  is  an  accident  of  common  occurrence 
after  parturition.  It  has  been  observed  after  abortion  at  the  second 
month,  when  the  elasticity  of  the  foetus  would  seem  to  make  it  un- 
likely on  a-priori  grounds ;  but  that  the  cervix  should  be  lacerated, 
it  is  enough  that  it  should  be  insufficiently  softened  and  dilated.  It 
is  almost  always  at  the  first  delivery,  according  to  Munde's  statis- 
tics, that  cervical  tears  occur;  though  it  is  possible  that  both  cervix 
and  perineum,  left  intact  by  former  child-births,  should  ultimately 
tear.  There  may  not  be  the  least  notch  in  the  cervix  of  a  woman 
who  has  had  children,  and  yet  a  considerable  laceration  may  occur. 


THE   PATHOLOGY   AND   ETIOLOGY    OF   METRITIS.  155 

The  pathological  importance  of  cervical  laceration  has  been  brought 
into  relief,  and  certainly  exaggerated,  by  Emmet,  who  goes  so  far 
as  to  say :  "  The  half  of  all  nterine  affections  in  women  who  have 
had  children  depend  upon  laceration  of  the  cervix." 

Pallen  estimates  the  proportionate  frequency  of  the  accident  as 
40  per  100;  while  according  to  Goodell  it  is  1  in  6.  Munde,  in  2,500 
women  which  had  been  delivered,  found  612  lacerations  [25%),  but 
only  280  (50#)  were  sufficiently  deep  to  have  any  pathological  impor- 
tance; the  others  cicatrized  or  gave  rise  to  but  little  complaint,  The 
degrees  and  varieties  of  laceration  are  very  variable;  we  can  distin- 
guish unilateral,  bilateral,  anterior,  posterior,  and  stellate  lacerations. 
The  bilateral  form  is  the  most  frequent;  then  comes  the  unilateral, 
then  the  stellate,  the  multiple,  the  posterior,  and,  finally,  at  the  end  of 
the  series,  the  anterior.  The  unilateral  has  been  most  often  observed 
on  the  left  side;  due  without  doubt  to  the  frequence  of  the  left  ante- 
rior occipito-iliac  presentation,  the  tear  being  made  by  the  occiput. 
When  the  laceration  is  deep  and  partly  healed  over,  there  is  a  feel- 
ing of  a  smooth  line  along  the  cervix,  sloping  toward  its  surface; 
sometimes,  in  the  vaginal  cul-de-sac,  at  the  base  of  the  broad  ligament, 
there  is  felt  a  small  hard  nodule,  probably  due  to  the  same  trauma- 
tism. 

In  the  stellate  form  the  clefts  are  usually  less  deep.  Finally,  one 
obtains  the  impression  of  a  laceration  in  some 'cases  in  which  I  believe 
nothing  of  the  kind  has  occurred;  I  mean  those  cases  where  the 
cervix  is  gaping  and  the  finger  finds  no  rent  whatever  in  its  cir- 
cumference. Defenders  of  the  pathogenic  influence  of  lacerations 
have  not  been  wanting  who  have  seen  in  such  cases  a  tear  in  the  in- 
ternal mucous  coat,  an  endotrachelian  laceration;  which  has  produced 
a  subinvolution  of  the  part  and  consequent  patency  of  the  cervical 
canal.  According  to  Munde  this  variety  should  be  considered  as  a 
subinvolution  of  the  cervix  with  paralysis  of  its  muscular  fibres. 
For  ease  of  description  it  has  been  proposed  to  divide  lacerations 
according  to  their  depth  in  three  degrees ;  the  first,  but  slightly  cleav- 
ing the  cervix ;  the  second,  dividing  it  through  most  of  its  length; 
and  the  third,  which  goes  down  to  the  vaginal  cul-de-sac  or  even 
beyond  (see  Plate).  It  is  possible  for  the  laceration  to  be  free  from 
any  accompanying  ulceration,  and  for  its  whole  surface  to  be  covered 
with  squamous  epithelium  like  the  rest  of  the  cervix.  This  cicatriz- 
ing of  the  torn  portion  without  reunion  of  the  lips  is  particularly 
observed  after  surgical  division  of  the  cervix  followed  by  vigorous 


EXPLANATION  OF  PLATES  III.  AND  IV. 


Fig.  1.— Catarrhal  Erosion  of  Nulliparous  Cervix. 

Fig.  2. — Cystic  Erosion  of  Parous  Cervix  with  Slight  Fissure. 

Pig.  3. — Deep  Stellate  Laceration  without  E version. 

Pig.  4.— Stellate  Laceration  with  Eversion  and  Cystic  Hyper- 
plasia. 

Pig.  5. — Slight  Laceration  with  Cystic  Hyperplasia  and  Eversion 
of  Anterior  Lip. 

Pig.  6. — Laceration  of  Muscular  Tissue  of  Cervix  not  Involving 
External  Os,  but  Producing  a  Relaxed,  Gaping  Condition 
of  that  Orifice. 

Pig.  7. — Deep  Unilateral  Laceration  with  Eversion. 

Fig.  8. — Slight  Bilateral  Laceration  with  Eversion. 

Pig.  9. — Moderate  Bilateral  Laceration  with  Eversion. 

Fig.  10. — Very  deep  Bilateral  Laceration  with  Eversion. 

Fig.  11. — Deep  Bilateral  Laceration  with  Eversion,  nearly  Cica- 
trized, but  with  both  Upper  Corners  Showing  Fresh  Break- 
ing Down  of  Cicatrix  (Ulceration). 

Fig.  12. — Cystic  and  Papillary  Hyperplasia  Simulating  Epitheli- 
oma. 

All  the  figures  are  shown  as  they  appear  in  the  left  semi-prone 
position  through  Sims'  speculum.  (From  paper  by  Munde" 
in  Am.  Jour.  Obst.,  etc.,  Vol.  XII. ,  1879,  p.  134.) 


I 


**  is*,  j?.  .v  j- ^  a«j|. 


THE   PATHOLOGY    AND    ETIOLOGY    OF    METRITIS.  157 

antisepsis.  When  it  occurs  after  parturition,  we  can,  therefore,  con- 
clude that  the  wound  has  wholly  escaped  infection.  In  the  oppo- 
site case  ulceration  is  produced;  and  then,  the  deeper  the  laceration 
and  the  more  the  lips  are  everted,  the  greater  is  the  ectropion.  This 
exposes  the  mucous  membrane  to  all  causes  of  vaginal  irritation, 
friction,  secretions,  contact  of  air,  etc.,  and  is  doubtless  an  efficient 
cause  of  the  morbid  processes  styled  ulceration.  The  cystic  and 
papilliform  changes  may  then  be  so  far  developed  and  so  largely 
displayed  that  the  everted  lips  have  the  appearance  of  a  fungus  of 
malignant  character. 

At  the  same  time  there  are  important  histological  alterations  in 
the  torn  cervix.  In  the  first  place  the  work  of  cicatrization  itself, 
and  its  consequent  contraction,  may  have  troublesome  results ;  it  con- 
presses  the  glands,  hastening  their  cystic  degeneration  and  the  hyper- 
trophy of  the  tissue  (cystic  hyperplasia).  This  dense  cicatricial  tissue, 
by  compressing  the  nerve  terminations,  can  give  rise  to  various  nerve 
disorders,  according  to  Emmet  and  his  disciples. 

It  is  especially  the  pressure  excited  by  the  superior  angle  of  the 
laceration,  according  to  this  gynaecologist  (who  has  so  magnified  the 
importance  of  this  little  accident) — it  is  in  the  pressure  in  the  superior 
angle,  which  he  calls  "  the  cicatricial  plug,"  that  the  trouble  has  its 
root;  and  he  sees  a  frequent  cause  of  nervous  disease  in  this,  even  in 
cases  where  but  little  complaint  is  made  of  the  cervical  deformity. 
Doleris 34  follows  Emmet,  insists  upon  the  cicatricial  plug,  and  attri- 
butes part  of  its  formation  to  a  parametritis  following  infection  of 
the  tear. 

Another  early  change  in  the  cervix  is  the  eversion  of  its  lips, 
caused  by  traction  of  the  vaginal  insertion  upon  the  divided  cervix; 
this  may  reach  extreme  ectropion  of  the  mucous  membrane,  which 
becomes  more  marked  as  the  disease  advances.  Finally  a  third  result 
of  laceration  may  be  arrest  of  post-partum  involution,  or  passive  con- 
gestion, catarrh,  etc. 

Pathogeny.  —The  majority  of  classic  authors  describe  the  different 
forms  of  metritis,  one  after  the  other,  in  complete  form,  and  the  study 
of  causes  is  found  distributed  among  many  sections,  as  if  each  type 
differed  in  all  parts.  •  It  seems  to  me  that  there  is  no  interest  in  fol- 
lowing this  tradition.  While  I  have  presented  the  anatomical  and 
pathological  studies  in  one  paragraph,  I  have  given  in  one  section  all 
the  causes,  and  so  avoid  useless  repetitions. 

From  the  point  of  view  of  pathogeny  one  may  say  that  all  inflam- 


158  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

mations  of  the  uterus  are  due  to  microbes;  that  is,  of  infectious 
origin. 35  This  has  now  been  directly  demonstrated,  so  that  there  re- 
mains no  more  doubt  on  the  subject.  This  opinion  now  generalized 
was  first  asserted  by  Schroeder.36  This  is  how  that  eminent  gynae- 
cologist expressed  himself  many  years  ago:  "Modern  notions  de- 
mand that  we  ascribe  a  very  special  importance  to  the  penetration 
of  noxious  agents  from  the  exterior  into  the  uterine  cavity.  All  that 
we  certainly  know  in  this  respect  is  that  gonorrhoeal  infections  may 
cause  acute  or  chronic  endometritis.  For  my  part  I  consider  that 
this  infection  plays  a  considerable  role  in  the  etiology  of  metritis; 
for  one  finds  at  the  same  time  that  there  is  vaginitis  and  a  cervical 
catarrh  of  recent  or  old  date.  However,  in  most  cases  of  endome- 
tritis, of  a  nature  plainly  gonorrhoeal,  the  vagina  may  be  entirely 
normal,  due  sometimes  to  the  fact  that  it  has  not  been  infected 
or  that  the  disease  has  been  present  and,  while  leaving  the  vagina, 
has  persisted  in  the  uterus.  Endometritis  which  follows  parturition 
is,  in  most  cases,  due  to  a  puerperal  infection  limited  entirely  to  the 
mucous  membrane  and  consequently  unable  to  cause  a  general  infec- 
tion. In  the  same  manner  we  can  explain  chronic  metritis,  which  we 
so  frequently  find  in  nullipara,  who  have  never  had  gonorrhoea,  and 
in  young  women  still  virgin.  Phlogogenic  agents  may,  in  the  same 
condition,  penetrate  the  uterine  cavity,  and  I  have  no  doubt  that  this 
penetration  may  sometimes  be  the  result  of  habits  of  masturbation." 

The  most  recent  researches  confirm  this  presumption,  and  this 
explains  without  doubt  the  gonorrhoeal  origin.  Steinschneider,37  in 
his  interesting  studies  on  the  seat  of  gonorrhoeal  infection  in  females, 
demonstrated  long  ago  that  after  the  gonococcus  had  disappeared 
from  the  urethra  it  could  still  be  found  in  the  cervix  or  body  of  the 
uterus,  as  the  mucous  membrane  there  is  better  fitted  for  its  culture 
than  that  of  the  vagina  because  of  the  unfavorable  circumstances 
dependent  upon  the  pavement  of  squamous  epithelium  of  the  latter, 
and  the  acidity  of  its  secretion,  together  with  the  coexistence  of  the 
numerous  bacteria  which  dwell  normally  within  the  cavity. 

The  same  direct  demonstration  is  not  so  easily  obtained  for  the 
micro-organisms  of  post-puerperal  endometritis. 

Goenner,  of  Basle,  has  found  in  cases  of  puerperal  fever  strepto- 
cocci which  are  very  easily  cultivated.  Doclerlein39  has  recently 
collected  the  lochia  of  a  parturient  woman  from  within  the  uterus 
itself.  These  lochia  were  examined  by  the  microscope,  and  by  cul- 
tures on  gelatin  and  agar-agar.     The  result  was  that  following  normal 


THE   PATHOLOGY   AND   ETIOLOGY   OF   METEITIS.  159 

labor,  with  a  temperature  not  beyond  38°  C.  (98.4°  F.),  there  were  no 
germs;  but,  when  there  was  fever,  bacilli  and  cocci  were  found  until 
the  temperature  fell,  they  being  then  eliminated  by  the  very  abund- 
ant secretion,  especially  when  it  was  purulent.  The  results  of  the 
pathological  labor,  and  also,  without  doubt,  of  the  consecutive  me- 
tritis, are  thus  due  to  the  pathogenic  influence  of  the  Streptococcus 
pyogenes.  Doderlein  thought  that  these  germs  were  carried  from  the 
vagina  into  the  uterus  by  the  exploratory  finger  or  instrument. 

Straus  and  Sanchez  Toledo  40  have  published  confirmatory  ex- 
periments, but  their  attempts  to  infect  the  uteri  of  rabbits  with 
septic  lochia  have  failed,  because  of  the  different  form  of  placenta  and 
the  absence  in  these  animals  of  a  decidua. 

Peraire 41  observed,  and  was  able  to  cultivate,  both  bacteria  and 
cocci  found  in  the  secretions  of  metritis;  and  the  inoculation  of 
rabbits  with  these  produced  both  fever  and  vaginitis. 

It  is,  then,  well  established  that  in  septic  metritis,  or,  better,  in 
the  infection  of  the  uterine  mucous  membrane  following  labor  or 
abortion,  the  cause  of  the  accident  is  a  proliferation  of  the  pathogenic 
microbes,  and  the  actual  metritis  which  persists  after  the  puerperal 
state  is  due  to  the  persistence  of  these  germs. 

A  much-discussed  question  is,  What  is  the  point  of  invasion  of 
these  microbes  ?  Do  they  always  come  from  the  exterior,  or  may 
they  come  from  within  ?  Are  they,  in  other  words,  a  hetero-infection 
or  an  auto-infection  ?  I  will  not  enter  into  the  long  discussions 
recently  provoked  by  this  subject ; 4a  it  is  enough  to  give  briefly 
the  conclusions  which  seem  to  me  to  be  trustworthy. 

Hetero-infection,  or  infection  by  contact  (Kaltenbach),  or  exogen- 
ous infection  (Fehling),  is  by  far  the  more  frequent;  it  is  indeed  the 
rule.  Leopold  found  an  enormous  diminution  of  the  death-rate  in 
his  service  after  he  had  forbidden  the  examination  of  pregnant  women; 
that  is,  in  spite  of  all  antiseptic  precautions  the  exploratory  finger 
may  be  the  vehicle  for  germs.  In  a  normal  labor  the  vagina  should 
be  considered  as  aseptic  (Bokelmann,  Diihrssen).  There  are  no  germs, 
as  I  have  stated,  in  the  lochia  of  a  normal  labor ;  they  are  not  to  be 
found  in  the  upper  portion  of  the  vagina  immediately  after  parturi- 
tion according  to  Ott ; 43  and  he  attributes  this  fact  to  the  cleansing 
action  of  the  waters  and  the  friction  of  the  foetal  body  upon  the 
vaginal  walls.  Thus,  if  everything  is  favorable,  with  no  retention  of 
foetal  debris,  with  no  accumulation  of  clots  from  atony  of  the  uterus, 
and  with  no  premature  rupture  of  the  membranes  preventing   the 


160  CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 

physiological  cleansing  of  the  genital  canal,  there  is  no  chance  what- 
ever of  infection.  This  is  the  explanation  of  the  kapioy  issne  of  so 
many  labors  where  no  precautions  have  been  taken,  for  Nature,  we 
are  accustomed  to  say,  has  provided  for  her  own  asepsis.  We  must, 
therefore,  beware  of  useless  interference  or  manipulation  in  simple 
cases,  and  abstain  from  meddling  with  antiseptic  injections  which 
may  be  useless,  and  therefore  dangerous. 

There  is  nothing  specific  in  a  bacterial  infection  of  the  uterus.  It 
is  an  error  long  since  laid  aside  to  think  that  each  special  infection 
corresponds  to  a  special  pathogenic  element.44  It  is  known  perfectly 
to-day  that  but  one  and  the  same  microbe,  the  Streptococcus  pyogenes, 
causes  all  the  septic  lesions  of  parturition,  and  is  also  produced  in 
erysipelas  and  furunculosis.45 

Puerperal  infection  of  the  uterus,  the  starting-point  of  consecutive 
metritis,  may  then  be  the  product  of  a  pathogenic  germ  coming  from 
various  sources.  It  is  demonstrated  to-day,  not  only  by  clinical  ex- 
perience, but  also  by  bacteriological  observation,  that  the  germs  which 
cause  surgical  infections,  boils,  and  erysipelas  may  infect  the  parturi- 
ent woman,  and  be  found  then  in  her  genital  secretions.  While  I  was 
interne  at  the  hospital  during  Broca's  service  I  had  many  opportuni- 
ties to  see  small  epidemics  of  erysipelas  in  the  surgical  wards  follow- 
ing puerperal  fever  in  the  obstetrical  wards  near  by.  This  mixed 
infection  has  been  made  the  subject,  during  the  last  years,  of  very 
interesting  works  from  the  pathogenic  point  of  view.  Pfannenstiel 
studied  a  little  epidemic  in  the  Breslau  Frauenklinic,  following  a  gen- 
eral attack  of  tonsillar  angina,  and  perfectly  demonstrated  their 
bacterial  relationship.46  The  streptococcus  of  erysipelas  (Str.  erysi- 
pelatis,  Fehleisen)  and  of  suppuration  (Str.  pyogenes,  Rosenbach)  are 
closely  related  and  seem  to  occur  equally  in  puerperal  infection.47 

Winter's  researches  on  this  subject  are  very  valuable,  because  of 
the  ability  of  the  author  and  the  rich  material  at  his  disposal,  thanks 
to  the  numerous  hysterectomies  and  salpingotomies  of  the  Berlin 
clinic.  This  fresh  material  removed  many  of  the  causes  of  error  of 
former  researches,  and  led  him  to  the  conclusion  that  in  the  genital 
canal  of  the  female  there  is  a  zone  rich  in  micro-organisms  which  I 
call  "  the  dangerous  zone."  Not  only  do  the  vagina  and  the  cervix 
contain  germs  in  abundance,  as  Hausmann,  Kiistner,  Lomer,  and 
Bumm 48  have  proved,  but  these  germs  are  pathogenic  in  the  majority 
of  Winter's  cases,49  the  species  which  prevail  being  staphylococci 
(pyogenes,  aureus,  albus,  and  citreus)  and  various  kinds  of  strepto- 


THE    PATHOLOGY    AND    ETIOLOGY    OF   METRITIS.  161 

cocci.  This  is  of  the  utmost  importance,  for  it  proves  the  possibility 
of  self-infection.  It  would  not  be  easy  to  understand  why  such  infec- 
tion does  not  occur  more  often,  in  every  labor  in  fact,  during  the 
period  of  rapid  multiplication  of  the  germs,  but  that  Winter  has 
shown  by  his  inoculations  with  cultures  obtained  at  that  time  that 
the  staphylococci  have  lost  their  virulence,  being  domesticated,  as  it 
were,  in  the  genital  passages.  "We  have  thus  an  example  of  sponta- 
neous attenuation  which  is  equally  remarkable  and  fortunate.  But 
it  is  quite  probable  that  this  virulence  might  be  rapidly  regained  under 
favoring  circumstances,  e.  r/.,  the  presence  of  organic  debris.  Thus  we 
can  understand  why  abortions  are  so  dangerous  from  bits  of  retained 
fcetal  structure,  the  uterine  infection  advancing  step  by  step.  It  is 
equally  plain  how  great  is  the  risk  of  making  uterine  exploration 
without  previous  cleansing  of  the  genital  canal;  even  though  the  finger 
and  the  sound  may  be  rendered  aseptic,  they  may  still  become  the 
vehicles  of  infection,  for  they  may  transport  germs  from  the  cervix 
into  the  body  of  the  uterus.  It  is  at  the  level  of  the  internal  os  that 
the  dangerous  zone  is  found. 

Certain  mechanical  conditions  may  aid  in  producing  uterine  infec- 
tion. Thus  Schultze 50  thinks  that  in  women  with  a  patulous  vulva,  as 
is  the  case  in  many  multipara  even  without  perineal  rupture,  a  slight 
leucorrhceal  discharge  may  carry  atmospheric  germs;  and  in  a  similar 
way  the  menstrual  discharge  may  act  in  women  with  a  closed  vulva. 
Hence  the  necessity,  according  to  Schultze,  of  protecting  the  part  by  a 
pad  which  will  filter  the  air. 

Other  germs  than  those  usually  found  in  the  vagina  or  cervix 
may  be  carried  by  the  sound  into  the  uterine  cavity.  In  large  towns 
we  live  in  the  midst  of  bacteria.  Eiselsberg 51  has  found  Staph,  pyog. 
aureus  in  the  wards  of  a  hospital  ;  Fiirbringer 5a  demonstrated  them 
in  matter  scraped  from  the  nails ;  Passet  found  them  in  dish-water, 
and  the  same  author  encountered  Staphy.  pygo.  albus  in  some  slightly 
damaged  beef,  etc.  Biondi 53  found  the  same  germ  in  normal  saliva. 
These  observations  prove  the  many  chances  of  infection,  which  would 
indeed  be  almost  inevitable  but  for  the  vital  force  of  living  tissue 
which  fights  against  it ;  Avhatever  lessens  this  force,  therefore,  opens 
the  door  to  infection. 

Some  of  the  most  curious  examples  of  such  action  is  found  in  what 
Verneuil  calls  latent  microbism,  for  we  do  not  have  to  do  with  an 
extinguished  danger,  but  with  an  infection  which  does  not  yet  exist, 
depending  for  its  development  upon  a  transformation  of  its  medium 


162  CLINICAL  AND   OPEEATIVE   GYNECOLOGY. 

from  physiological  to  pathological  conditions.  Auto-infection,  or,  as 
Fehling  styles  it,  endogenous  infection,  is  thus  reduced  to  a  question 
of  culture  media,  producing  virulence  in  an  organism  before  inactive. 
Thus  Chauveau54  restored  the  powers  of  charbon  (anthrax)  bacilli  by 
cultivating  them  in  rarefied  air  in  blood-plasma  and  bouillon.  If  this 
faculty  of  increasing  the  noxious  powers  of  germs  residing  in  the 
female  genitalia  belongs  to  organic  debris,  may  it  not  be  called  forth 
by  other  means  ?  Could  not  general  debility  of  all  the  tissues,  which 
reduces  cellular  vitality,  or  traumatism,  with  its  inhibitory  action 
(Brown- Sequard),  raise  the  barrier  of  phagocytism  which  keeps 
all  germs  out  of  the  body  or  renders  them  inoffensive  ?  Perhaps 
we  may  thus  explain  the  effect  of  certain  diseases,  as  eruptive  fevers, 
and  also  of  venereal  excess. 

Moreover,  it  has  been  shown  that  the  presence  of  one  germ  aids 
the  development  of  another  species.  Thus  women  with  gonorrhceal 
metritis  (Neisser's  gonococcus)  are  easily  infected  with  septic  material 
more  or  less  attenuated,  as  staph ylo-  and  strepto-cocci  or  even 
tubercle  bacilli.  Such  may  be  termed  mixed  infection.  Thus  the 
lesions  of  pneumonia  prepare  the  lung  for  the  invasion  of  the  tuber- 
cle bacillus  (Koch). 

Etiology. — Passing  now  to  the  direct  causes  of  metritis  we  find 
them  associated  with,  1st,  menstruation;  2d,  copulation;  3d,  parturi- 
tion; 4th,  traumatism. 

1.  Menstruation. — The  establishment  of  the  catamenia  may  be  the 
signal  for  metritis  to  manifest  itself,  because  of  the  intense  congestion 
of  a  peculiarly  vulnerable  organ.  There  is  generally  present  in  such 
a  case  some  malformation  of  the  uterus  which  induces  venous  stasis ; 
incomplete  development,  congenital  anteflexion,  a  conical  cervix,  ste- 
nosis of  the  os,  exposure  to  cold,  and  masturbation  may  be  some  of 
these  primary  or  secondary  causes.  To  this  virginal 55  metritis,  there 
is,  at  the  other  pole  of  the  woman's  genital  career,  a  corresponding 
metritis  of  the  menopause,  for  at  that  time  again  there  may  be  a  pre- 
disposing active  congestion. 

Between  these  two  extremes  every  menstrual  period  favors  the 
development  of  metritis,  and  every  extra  fatigue  or  exposure  to  cold 
may  bring  it  on  if  the  uterus  is  malposed,  if  the  cervix  is  contracted, 
or  if  there  is  a  deep  laceration  from  previous  labor. 

2.  Copulation. — Excessive  coitus,  whether  during  menstruation  or 
coincident  with  great 56  fatigue,  may  provoke  uterine  inflammation 
independently  of  all  contamination ;  but  far  more  often  it  is  a  gonor- 


THE   PATHOLOGY   AND    ETIOLOGY    OF    METRITIS.  163 

rhceal  infection,  more  or  less  disregarded,  which  is  so  efficient  a 
cause  "of  metritis  and  which  plays  this  role  in  the  case  of  newly- 
married  women.  Husbands  who  consider  themselves  cured  and  pay 
no  attention  to  a  trifling  urethral  discharge  may  thus  infect  the  ure- 
thra, the  vagina,  the  cervical  and  uterine  cavities,  and  the  tubes  of  the 
young  wife. 

Such  a  gonorrheal  infection  may  remain  a  long  time  latent  within 
the  cervix ;  then  under  the  irritation  of  a  rough  examination,  or  after 
abortion  or  labor,  the  infection  gains  entrance  to  the  body  of  the 
uterus.  Noeggerath 58  asserts  that  in  women  with  gonorrhoea  abortion 
and  labor  are  followed  by  metritis  and  perimetritis  as  often  as  75 fc ; 
substituting  salpingitis  for  perimetritis,  the  statement  is  not  exagger- 
ated. It  is  doubtless  to  this  cause,  also,  rather  than  to  the  traumatism 
of  too  frequent  coitus,  that  we  must  refer  the  metritis  of  prostitutes. 
Abortions  are  frequent  and  unheeded  among  women  who  are  beginning 
a  debauched  life,  and  later  the  inflammation  of  the  uterus  rises  high 
enough  to  involve  the  tubes,  obliterating  them  and  causing  sterility. 

3.  Parturition.— This  is  by  far  the  most  frequent  cause.  Normal 
labor,  spontaneous  and  induced  abortion,  leave  the  uterus  in  a  pecu- 
liar  condition  of  hyperplasia  and  congestion  which  demand  special 
hygienic  conditions  for  their  gradual  removal;  "but  these  conditions 
are  often  neglected,  from  carelessness  among  the  well  to-do,  from 
necessity  among  the  laboring  classes.  It  is  not  so  very  long  ago  that 
celebrated  obstetricians  considered  fifteen  to  twenty  days'  rest  suffi- 
cient (Cazeaux).  Guerin  justly  opposed  this  fixed  rule,  advising  that 
the  patient  should  not  be  permitted  to  leave  her  bed  till  a  week  after 
the  first  menstrual  period;  for  only  by  that  time  has  the  uterus 
regained  its  normal  size.56  Without  such  care  Ave  see  a  post-puerperal 
engorgement  intervening,  which  is  Chomel's  "  post-puerperal  metritis  " 
and  Simpson's  "arrested  involution;"  the  chronic  metritis,  uterine 
infarction,  chronic  and  painful  metritis  of  other  authors. 

When  parturition  has  been  abnormal,  by  reason  of  difficult  deliv- 
ery, and  when  pieces  of  placental  detritus  have  remained  a  long  time 
in  the  uterine  cavity,  then  the  organ  is  specially  liable  to  inflamma- 
tion. At  such  a  time  there  can  be  no  doubt  that  we  have  a  local  in- 
fection, and  if  a  rigorous  antiseptic  treatment  is  not  at  once  begun, 
there  is  reason  to  fear  that  the  disease  may  persist  in  chronic  form. 
The  same  is  true  of  abortion  where,  as  is  so  frequently  seen,  small 
portions  of  the  decidua  graft  themselves  upon  the  mucous  mem- 
brane and  become  centres  of  infection  for  it. 


164  CLINICAL   AND   OPEEATIVE   GYNAECOLOGY. 

One  condition  in  particular  has  recently  been  insisted  upon  as  of 
great  influence  in  establishing  and  prolonging  metritis,  and  that  is 
cervical  laceration,  as  Emmet 59  styles  it.  This  American  gynaecolo- 
gist was  the  first  to  recognize  its  importance  (in  1869),  though  Ben- 
net  60  had  dimly  foreseen  it  some  time  before.  But  in  America  there 
is  a  disposition  to  exaggerate  the  influence  of  this  lesion. 

It  is  customary  to  attribute  many  consequences  to  cervical  lacera- 
tion ;  as  delay  of  the  normal  uterine  involution  after  labor,  then 
hyperplasia,  sclerosis,  and  compression  of  the  nerve  filaments ;  ovarian 
congestion  and  inflammation;  parametritis;  extension  of  the  sclero- 
sis from  the  laceration  to  the  rest  of  the  cervix  with  compression  of 
the  nerves  and  glands  and  production  of  cysts  locally  and  neuralgias 
and  neuroses  in  general ;  ectropion  and  inflammation  of  the  cervical 
mucous  membrane  following  the  traumatism  to  which  it  is  exposed ; 
tendency  to  retroversion  and  prolapse.  Nor  is  this  all;  Munde,61 
Olshausen,62  Hegar  and  Kaltenbach 63  consider  old  lacerations  a  fre- 
quent cause  of  habitual  abortion ;  Breisky 64  thinks  that  they  predis- 
pose to  carcinoma,  affording  a  locus  minoris  resistentise.  Emmet's 
ideas  on  the  pathological  influence  of  laceration  have  given  rise  to 
many  long  discussions,  some  of  which  are  very  recent.  At  the  meet- 
ing of  German  naturalists  held  in  Wiesbaden,  September,  1887,  Noeg- 
gerath 65  presented  a  long  statistical  paper  which  was  intended  to  re- 
duce the  role  of  cervical  laceration  to  nothing  by  demonstrating  the 
following  rjropositions : 

1.  Women  with  laceration  of  the  cervix  conceive  more  easily  and 
abort  less  than  others. 

2.  The  position  of  the  uterus  is  not  influenced  by  laceration. 
).  The  cavity  of  the  uterus  is  not  elongated. 

4.  Erosion  and  ulceration  are  not  more  frequent. 

5.  Ectropion  never  results. 

6.  Alteration  in  the  cervical  tissues  is  not  more  frequent. 

7.  Laceration  produces  no  change  in  the  frequency  or  severity  of 
nterine  disease. 

In  the  discussion  which  followed  the  reading  of  this  memoir, 
Sanger,  Ahlfeld,  and  Skutsch  declared  that  Noeggerath  had  gone  too 
far  in  his  criticism ;  and  not  long  afterward,  Brooks  Wells 66  published 
i  carefully-written  paper  which  refuted  Noeggerath's  position  point 
oy  point.  Wells  also  employed  statistics,  but  he  arrived  at  a  directly 
opposite  result,  insisting  especially  upon  the  importance  of  lacera- 
tion in  the  production  of  reflex  neuroses. 


THE   PATHOLOGY   AND   ETIOLOGY   OF   METRITIS.  165 

It  is  difficult  to  give  a  categorical  opinion  amid  assertions  so  con- 
tradictory and  so  authoritative.  It  seems  to  me  that  the  role  of  lacer- 
ation has  been  alternately  too  much  exalted  and  belittled.  It  is 
false  to  suppose  that  no  other  cause  for  uterine  malpositions  exists, 
or  to  attribute  all  inflammations  of  the  organ  and  its  adnexa  to  lacer- 
ation alone.  At  present  it  is  generally  agreed  that  uterine  displace- 
ments may  give  rise  to  nervous  phenomena,  but  they  cannot  be  said 
to  cause  metritis,  however  much  they  predispose  thereto.  This  then 
is  the  limit  of  the  influence  of  laceration — it  may  cause  morbid  re- 
flexes, and  predispose  to  cervical  catarrh  and  prolong  it.  But  there 
are  many  cases  of  retroversion  without  symptoms,  and  as  many  of 
laceration  without  metritis;  at  the  same  time  there  are  lacerations 
which  extend  to  the  cellular  tissue  of  the  cul-de-sac,  and  bilateral 
forms  with  marked  ectroyjion,  which  have  a  pathological  importance 
that  cannot  be  neglected. 

Traumatism. — Chronic  contusions,  produced  by  a  pessary  that  is 
too  large  or  badly  placed,  so  that  it  exerts  strong  pressure  upon  the 
uterus,  may  give  rise  to  acute  symptoms  of  metritis  which  disappear 
as  soon  as  the  instrument  is  removed;  and  of  all  pessaries,  those 
with  an  infra-uterine  stem  are  the  most  dangerous,  unless  carefully 
watched  by  the  surgeon. 

Finally,  any  operation  whatever  within  the  genital  canal  may  be 
the  starting-point  of  metritis  (with  or  without  parametritis  and  peri- 
metritis) if  strict  antisepsis  has  not  been  maintained.  Such  acci- 
dents, so  frequent  that  gynaecologists  were  justly  timorous,  exist  no 
longer  in  the  practice  of  those  who  observe  the  rules — which  might 
almost  be  called  sacred — of  modern  surgery ;  for  to-day  even  if  inflam- 
mation do  occur  after  operations  within  the  uterine  cavity,  it  may,  to 
a  certain  point,  be  kept  from  becoming  septic,  and  permanent  re- 
sults prevented. 

Yery  hot  or  cold  vaginal  injections  have  been  accused  of  causing 
metritis ;  for  my  part,  I  lay  but  little  stress  upon  them  as  a  cause :  an 
injection  may  do  harm  if  the  tube  is  ill-fitting  or  if  force  enough  be 
used  to  injure  the  cervix.  In  prolapse,  for  instance,  the  injection  tube 
has  been  passed  into  the  cervix  and  serious  accidents  have  followed; 
but  this  has  nothing  to  do  with  metritis. 

Otlier  Causes.— Ought  we  to  regard  the  exanthemata  as  a  cause  of 
metritis,  as  certain  authors  have  done 67  ?  It  seems  to  me  that  new 
observations  are  needed  upon  this  point.  We  cannot  deny  that  the 
female  genital  tract  may  be  more  exposed  to  disease  after  a  general 


166  CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 

affection  which  has  enfeebled  the  entire  organism.  Certain  maladies 
(icterus)  and  some  poisons  (phosphorus)  may  produce  an  acute  fatty 
degeneration  of  the  uterus ;  but  that  is  a  lesion,  not  a  disease,  and  it 
is  a  mistake  to  insist  upon  it  in  connection  with  metritis. 

The  influence  of  diathesis  has  been  very  much  exaggerated.  Mar- 
tineau 6S  has  even  classified  metritis  into  constitutional  and  traumatic. 
According  to  him,  constitutional  metritis  is  partly  protojDathic  and 
partly  deuteropathic,  arising  from  scrofula,  arthritis,  herpes,  chloro- 
sis, syphilis,  or  tuberculosis. 

I  consider  it  a  misuse  of  language  to  describe  a  scrofulous  or  her- 
petic metritis,  as  if  they  possessed  clear-cut  boundaries.  I  willingly 
grant  that  general  conditions  and  place  involved  play  a  great  role,  if 
not  in  the  production,  at  least  in  the  permanence  of  local  inflamma- 
tion, particularly  of  metritis ;  and  that  we  must  carefully  examine  the 
general  state  of  a  patient  before  attempting  treatment.  But  this  is 
all  that  I  can  concede  to  diathesis. 

BIBLIOGRAPHY. 

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739  and  804 ;  also  Guerin  :  Lecons  Cliniques  sur  les  Maladies  des  Organes  Gehitaux 
Internes  de  la  Femme,  Paris,  1878,  page  218. 

2.  Wyder:   Die  Mucosa  Uteri  bei  Myomen,  Arch.  f.  Gyn.,  Bd.  xxix. 

3.  Czempin :  Ueber  die  Beziehung  der  Uterussehleimhaut  zu  den  Erkran- 
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p.  455. 

5.  De  SinSty  :   Traite  Pratique  de  Gyn.,  2d  ed.,  Paris,  1884,  page  372. 

6.  lam  indebted  to  M.  Cornil  for  these  beautiful  figures  from  his  "Lecons" 
published  by  the  Jour,  des  Sci.  MM.,  1888. 

7.  Soc.  de  Chir.,  Dec.  2d,  1868. 

8.  Berliner  Zeit.  f.  Geb.  und  Gyn.,  1873,  iii.,  page  33. 

9.  Dublin  Jour.  Med.  Sci.,  August,  1887. 

10.  Theo.  Wyder  :  Arch.  f.  Gyn.,  Bd.  xiii.,  page  43  ;  and  Meyer  -.  Zur  Path,  der 
Dysmen.  memb.     Arch.  f.  Gyn.,  Bd.  xxi.,  Heft  L,  page  56. 

11.  Scanzoni :   De  la  M^trite  Chronique,  French  edition,  page  37. 

12.  Finn  of  St.  Petersburg.     Centr.  f.  die  med.  Wissensch.,  Sept.,  1868,  p.  564. 

13.  Cornil :  Anatomie  Path,  des  Metrites.  Jour,  des  Connaissances  m6dicales, 
June  21st,  1888. 

14.  Cornil :  Lecons  sur  les  Metrites.  Jour,  de*  Connaissances  mMicales,  April 
5th,  1888. 

15.  Theo.  Wyder:  Tafeln  fur  den  gyn.  Unterricht,  Berlin,  1887,  plates  x.,  xi., 
and  xii. 

16.  Cornil :  Lecons  sur  l1  Anatomie  pathol.  des  Metrites.  Journal  des  Connais- 
sances meYlicales,  April  21st,  1888. 

17.  R6camier  :   Union  m£dicale  de  Paris,  June  1st  to  8th,  1850. 

18.  DeSin£ty:  Manuel  de  Gynecologie,  2d  ed.,  1884. 

19.  Zweifel :  Centr.  f.  Gyn.,  1888,  page  408. 


THE    PATHOLOGY    AND    ETIOLOGY    OF    METRITIS.  107 

20.  Frankel  :    Centr.  f.  Gyn.,  1888,  page  347. 

31.  Schroder  :   Malad,  des  Org.  G£nit.  de  la  Fern.,  French  ed.,  1886,  p.  125. 

22.  Peraire  :  Des  Endometrites  Infectieuses,  Pai-is,  1889. 

23.  Courty  :   Trait<3  Prat,  des  Mai.  de  FUterus,  page  1,059. 

24.  Fischel :  Beit,  zur  Histol.  der  Eros,  der  Port.  vag.  Arch,  fiir  Gyn.,  xv.,  p. 
70,  xvi.,  p.  191  ;  also  Die  Erosion  und  das  Ectrop.  Centr.  f.  Gyn.,  1880,  pages  425 
and  585. 

25.  Klotz  :    Gyniikologische  Studien,  Vienna,  1879. 

20.  Gosselin  :  De  la  Yaleur  Syinptomatique  des  Ulceres  du  Col  Uterin.  Arch, 
gen.  de  Medecine,  1843,  vol.  xxiii.  Cliniques  de  FHopital  de  la  Charity,  1879,  vol. 
iii.,  p.  42. 

27.  Melier :  Considerations  Pratiques  sur  le  Traitement  des  Maladies  de  la 
Matrice.     Memoires  deFAcadeinie  de  Med.,  1833.  vol.  ii.,  p.  330. 

28.  Tyler  Smith:   Med.-Chir.  Transact.,  1852,  xxxv.,  p.  398. 

29.  Roser:   Das  Ectropium  am  Muttermund.     Arch,  der  Heilk.,  1881,  ii.,  p.  97. 

30.  Bouilly  :  La  Sem.  in<5d.,  Sept.  oth,  1888  ;  also  Bennett :  Practical  Treatise 
on  Inflammation  of  the  Uterus,  1864. 

31.  Ruge  and  Veit :  Centralbl.  f.  Gyn.,  1877,  No.  2,  and  Zeitschrift  f.  Geburtsh. 
und  Gyn.,  Bd.  ii.,  p.  415,  and  Bd.  viii.,  p.  405.  De  Sinety  :  Des  Ulcerations  du  Col 
de  FUtems  dans  la  M6trite  Chronique.  Comptes  rendus  de  la  Soc.  de  Biologie,  et 
Assoc  Franc,  pour  l'Avanc.  des  Sciences,  1880. 

32.  Gomet  :  Paris  Thesis,  1889. 

33.  Doderlein :   Centr.  f.  Gyn.,  1889,  No.  6. 

34.  Doleris  :   Nouv.  Arch.  d'Obst.  et  de  Gynee.,  1888,  page  50. 

35.  Doleris  :  De  FEndometrite  et  de  son  Traitement.  Nouv.  Arch.  d'Obst.  et 
de  Gyn.,  1887  ;  also  Peraire  :  Des  Metrites  Infectieuses,  These  de  Paris,  1889. 

36.  Schroder  :  Malad.  des  Org.  G6nit.  de  la  Femme,  French  ed.,  Brussels,  1886, 
p.  117. 

37.  Steinschneider  :   Berliner  klin.  "YVochenschr.,  1887,  No.  17. 

38.  Alf.  Goenner  :  Ueber  Mikroorganismen  ini  Secret  der  weiblichen  Genitalien 
wahrend  der  Schwangerschaft  und  bei  puerperalen  Erkrankungen.  Centralbl.  f. 
Gyn.,  1887,  No.  28. 

39.  Doderlein :  Ueber  Yorkommen  und  Bedeutung  der  Mikroorganismen  in 
den  Lochien  gesunder  und  kranker  Wochnerinnen.  Centr.  f.  Gynak.,  1888,  Nos.  23 
and  28.  D'apres  Doleris  :  Essai  sur  la  Pathog^nie  et  la  Therapeutique  des  Acci- 
dents Infectieux  des  Suites  de  Couches,  These  de  Paris,  1880,  p.  95. 

40.  Straus  and  Sanchez  Toledo :  Recherches  Microbiologiques  sur  FUt6rus 
apres  la  Parturition  Physiologique.     Annales  de  lTnstitut  Pasteur,  ii.,  p.   426. 

41.  Peraire  :   Loco  citato. 

42.  Bokelmann  :  Obst.  and  Gyn.  Society  of  Berlin,  May  24th,  1889.  Centr.  fiir 
Gyn.,  1889,  No.  29.  Kaltenbach  :  Ueber  die  Frage  der  Selbstinfektion.  Third  Ger- 
man Gynaecological  Congress,  Freiburg,  June,  1889.     Centr.  f.  Gyn.,  1889,  No.  27. 

43.  Yon  Ott :  Zur  Bakteriologie  der  Lochien.  Arch.  f.  Gynak.,  Bd.  xxxii., 
Heft  3. 

44.  Bouchard  :  Utilite  Pratique  des  Notions  Pathogeniques.  Semaine  m<?di- 
cale,  1889. 

45.  E.  Czerniewski :  Zur  Frage  von  den  puerperalen  Erkrankungen.  Arch.  f. 
Gyn.,  Bd.  xxxiii.,  Heft  1. 

46.  Pfannenstiel  :  Kasuistische  Beitrage  zur  Aetiologie  der  Puerperalfiebers. 
Centr.  f.  Gyn.,  1888,  No.  38  ;  see  also  Hartmann  :  Ueber  die  Aetiologie  von  Erysip. 
und  Puerperalfieber.  Dissert,  inaug.,  Munich,  1887.  Maierowiecz  :  Zur  Aetiologie 
des  Erysipels,  dissert,  inaug.  St.  Petersburg,  in  Centr.  f.  Bakteriol.,  hi.,  Bd.  i.,  1888. 
Von  Eiselsberg:   Arch.  f.  Chirurgie,  Bd.  xxxv.,  Heft  1,  1887. 


168  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

47.  Buinin:   Die  Puerp.  Infection.     Centr.  f.  Bakteriol.,  Bd.  ii.,  p.  343,  1887. 

48.  Hausmann  :  Die  Parasiten  der  weiblichen  Geschlechtsorgane,  Berlin,  1870. 
Kiistner :  Beitrage  zur  Lehre  der  Endometritis,  Jan.,  1883.  Lonier :  Die  Mikro- 
organisnien  der  -weiblichen  Gonorrhoe.  Deutsche  ined.  Wochensch.,  1885.  Bumm: 
Archiv  f .  Gyn.,  Bd.  xxiii.,  p.  237. 

49.  G.  Winter :  Die  Mikroorganismen  hn  Genitalkanal  der  gesunden  Prau. 
Zeitsehr.  f.  Geburtsh.  und  Gyn.,  1888,  Bd.  xiv.,  Heft  2. 

50.  Schultze:  Zur  Aetiologie  und  Prophylaxie  der  Genitalerkrankungen  des 
Weibes.    Wien.  med.  Blatt,  1882,  No.  52. 

51.  Yon  Eiselsberg  :   Langenbeck's  Archiv,  Bd.  xxxv.,  Heft  1. 

52.  Pilrbringer  :  Desinfection  der  Hande  des  Arztes,  page  21. 

53.  Biondi :  Centr.  f .  Bakteriologie,  cited  by  Winter. 

54.  Chauveau  :  Recherches  sur  la  Variability  Ascendante  du  Bacillus  Anthracis. 
Coniptes  Rendus  Acad,  des  Sciences,  Oct.  14th,  1889. 

55.  Paul  Bouton  :   De  la  M£trite  chez  les  Vierges.     These  de  Paris,  1886. 

56.  Alph.  Gu£rin  :  Lecons  clin.  sur  les  Malad.  des  Organes  Genitaux  int.  de  la 
Femnie,  Paris,  1878,  pages  28  and  145. 

57.  R6"uiy  :  Blennorrhagie  de  1' Uterus,  He" trite  Muqueuse  Blennorrhagique. 
Annales  de  Gynec,  1879. 

58.  Noggerath  :  Ueber  latente  Gonorrhoe,  p.  11 ;  also  Archiv  fur  Gynak.*  Bd. 
xxxii.,  Heft  2.  Kroner  :  Ueber  die  Beziehung  der  Gonorrhoe  zu  den  Generations- 
vorgangen.     Arch.  f.  Gynak.,  Bd.  xxxi.,  Heft  2. 

59.  Eniniet's  first  paper  was  read  before  the  Co.  Med.  Society,  N.  Y.,  Feb.  8th, 
1869,  Araer.  Jour.  Obst.,  Feb.,  1869.  The  second  paper,  Sept.  28th,  1871,  Amer. 
Jour.  Obst.,  Nov.,  1874,  is  the  one  usually  cited.  A  German  translation  by  Vogel 
introduced  the  subject  to  the  European  profession,  especially  after  Breisky's  favor- 
able criticism,  Wien.  med.  Woch.,  1876,  Nos.  49-51. 

60.  Bennett :   Traite"  Pratique  de  rinflammation  de  TUterus,  Paris,  1850. 

61.  P.  F.  Munde  :  American  Journal  of  Obstetrics,  Oct.,  1879,  and  Minor  Sur- 
gical Gynaecology,  New  York,  1885,  p.  430. 

62.  Olshausen  :  Zur  Pathologie  der  Cervicalrisse.     Centr.  f.  Gyn.,  1877,  No.  13. 

63.  Hegar  and  Kaltenbach  :  Loc.  cit. 

64.  Breisky  :  Allg.  Wien.  med.  Zeitsch.,  1882,  52. 

65.  Noggerath  :   Centr.  f.  Gyn.,  1888,  No.  41. 

66.  Brooks  H.  Wells  :  The  Etiological  Relation  of  Cervical  Laceration  to  Ute- 
rine Disease.    Amer.  Journal  of  Obstetrics,  March,  1888,  p.  257. 

67.  Siredey  :  Art,  MStrite  du  Diet,  de  MeU  et  de  Chir.  Prat.,  p.  031. 

68.  Martineau  :   Lecons  sur  la  Th6"rapeutique  de  la  Metrite,  Paris,  1887,  p.  23. 


CHAPTER  VI. 

SYMPTOMS,   COURSE,  AND   DIAGNOSIS   OF   METRITIS. 

After  studying  the  diseases  of  the  internal  genital  organs  of  the 
female,  it  is  impossible  not  to  be  struck  by  the  similarity  of  the  ra- 
tional signs  obtained  by  questioning  the  patient.  The  symptom- 
complex  differs  but  little  whether  the  case  is  one  of  chronic  metritis, 
catarrhal  endometritis,  fibroma,  cancer,  or  salpingitis.  Of  course  I  do 
not  go  so  far  as  to  say  that  they  are  identical,  for  if  the  questions  are 
sufficiently  precise,  sensible  differences  are  found  in  the  intensity  of 
special  symptoms.  But  although  a  certain  part  of  the  picture  may  be 
particularly  clear— as  the  hemorrhage  in  fibroma,  leucorrhcea  in  can- 
cer, nervous  troubles  in  displacements  or  disease  of  the  adnexa — it  is 
not  the  less  true  that  the  chief  features  are  the  same :  different  states 
of  the  same  plate,  often  retouched. 

By  the  term  *k  uterine  syndroma "  I  would  express  the  common 
symptomatic  basis  which  I  have  found — as  Beau  grouped  in  his  asys- 
tolic  syndroma  all  the  phenomena  of  cardiac  disease  when  the  heart 
arrives  at  its  period  of  fatigue,  whether  the  lesion  be  mitral,  tricuspid, 
or  aortic.  I  think  I  have  found  the  same  interest  in  the  clinical  syn- 
thesis which  I  propose ;  for  I  believe  that  with  this  sketch  it  will  be 
enough  for  the  special  case  to  fill  in  the  necessary  touches,  so  avoid- 
ing useless  repetitions. 

This  study  of  the  uterine  syndroma  naturally  has  its  place  here, 
as  it  so  closely  corresponds  to  the  rational  signs  of  metritis.  The 
principal  features  of  the  uterine  syndroma  are : 

Pain,  leucorrhcea,  dysmenorrhcea,  metrorrhagia,  symptoms  from 
neighboring  organs  (bladder,  rectum),  symptoms  from  distant  organs 
(digestive  canal,  nerves,  etc.). 

I  will  pass  these  successively  in  review. 

The  pain  is  spontaneous;  its  seat  is  in  the  smaller  pelvic  cavity, 
but  its  focus  is  not  always  at  the  same  level  as  the  uterus ;  it  is  not 
in  the  hypogastric  region  that  the  patient  suffers  the  most,  but  fre- 
quently in  the  iliac  fossa,  especially  the  left  near  the  ovary.  To  ex- 
plain this  fact  it  seems  reasonable  to  admit  the  presence  of  a  slight 


170  CLINICAL    AND    OPERATIVE    GYNECOLOGY. 

catarrhal,  salpingitis  with  uterine  inflammation.  The  tubes  are  sim- 
ply prolongations  of  the  uterus ;  anatomically  and  pathologically  the 
two  organs  are  the  same.  The  term  metritis  should  include  almost 
always  metro-salpingitis,  with  unequal  distribution  of  the  inflamma- 
tion ;  that  of  the  uterus  predominating,  that  of  the  tube  being  not  less 
real;  as  to  the  predominance  of  the  left  side,  it  is  as  difficult  to 
explain  as  epididymitis  on  the  same  side. 

Another  focus  of  pain  is  found  in  the  lumbar  region. 

This  pain  is  increased  by  all  fatigue,  such  as  the  jolting  of  a  car- 
riage ;  but  such  mechanical  influences  may  not  produce  an  immediate 
increase ;  the  exacerbation  may  come  on  only  after  the  lapse  of  some 
time.  Riding  in  the  horse-cars  is  usually  well  borne,  but  railroad 
travelling  it  is  injurious  because  of  the  peculiar  shaking  endured.  The 
pain  is  dull,  persistent,  giving  a  feeling  of  weight  and  fulness  in  the 
perineum  and  lower  pelvis ;  seeming  to  the  patient  as  if  there  were  a 
foreign  body  there,  tending  to  escape — that  is,  she  feels  her  own 
uterus.  The  bent  position  in  walking  in  acute  cases  is  characteristic ; 
instead  of  seating  herself  hurriedly,  the  patient  does  it  with  great 
care,  helping  herself  with  the  support  of  a  piece  of  furniture  near  by, 
like  the  arm  of  a  sofa,  lest  she  reawaken  the  slumbering  pain.  The 
distress  is  increased  by  pressure,  especially  in  bimanual  palpation; 
but  one  can  assure  himself  that  it  is  not  so  much  the  direct  pressure 
upon  the  cervix  which  is  painful,  as  the  part  is  not  sensitive  (except 
in  lumbo-abdominal  neuralgia),  but  the  transmitted  shock  to  the 
uterus  itself.     Gosselin  has  long  insisted  upon  this  distinction.1 

Leucorrhcea. — This  is  a  constant  symptom.  It  may  be  more  or  less 
masked  by  the  blood  or  pus  present  in  the  discharges,  but  it  is  always 
present ;  singly  or  in  combination. 

Leucorrhcea  (whites,  etc.)  is  a  phenomenon  so  important  in  gynae- 
cology that  some  of  the  older  authors 2  made  it  the  principal  disease 
of  the  uterus  and  grouped  all  the  others  about  it.  Even  Courty 
makes  leucorrhoea  an  entity,  an  idiopathic  affection,  in  certain  cases.3 

Leucorrhcea  is  a  morbid  alteration  and  exaggeration  of  the  physi- 
ological uterine  and  vaginal  secretions.  In  a  state  of  health  these 
parts  secrete  in  small  quantity  a  mucous  liquid  which  always  contains 
a  few  leucocytes,  due  to  the  destruction  of  the  local  epithelium.  As 
soon  as  this  has  become  abundant  and  purulent,  it  is  morbid  and  con- 
stitutes a  leucorrhoea. 

This  may  be  from  two  sources — the  uterus  or  the  vagina. 

Vaginal  leucorrhcea  may  often  be  found  alone;  it  may  be  a  dis- 


SYMPTOMS,    COURSE,   AND   DIAGNOSIS    OF   METRITIS.  171 

charge  of  very  thin  fluid  of  a  milky  appearance,  which  does  not  stain 
the  linen  much,  or  it  may  be  charged  with  pus  and  be  of  a  greenish- 
yellow  color;  its  reaction  is  acid. 

Leucorrhoea  from  the  body  of  the  uterus  is  of  a  somewhat  viscid 
nature ;  that  from  the  cervix  is  jelly-like  and  in  the  normal  state  is 
transparent,  like  the  unboiled  white  of  egg,  staining  the  linen  strong- 
ly ;  in  disease  it  is  of  a  greenish-yellow  color.  Its  reaction  is  alka- 
line. 

O.  Kiistner 4  has  made  precise  researches  upon  the  uterine  secre- 
tion, both  normal  and  diseased.  He  introduced  glass  tubes  into  the 
uterus  and  then  carefully  closed  the  external  os  with  collodion  and 
diachylon.  In  this  way  he  examined  six  women  who  were  free  from 
uterine  catarrh,  and  found  that  the  secretion  of  the  uterine  neck  and 
body  had  the  characters  I  have  indicated.  Afterward  he  examined 
women  with  uterine  catarrh,  with  or  without  puralence,  and  demon- 
strated that  most  often  the  inflammation  was  present  in  both  cervix 
and  body ;  and  that  isolated  catarrh  of  the  cervix  was  more  frequent 
than  isolated  catarrh  of  the  body  of  the  organ.  In  all  his  cases 
Kiistner,  by  the  microscope,  demonstrated  the  presence  of  micro- 
organisms in  great  quantity,  having  for  the  most  part  an  oval  form, 
and  presenting  four  or  five  distinct  types.  The  recent  researches  of 
Winter,  as  stated  above,  show  that  these  germs  are  identical  in  form 
with  pathogenic  varieties. 

The  leucorrhoeal  secretion  is  seldom  voided  by  steady  flow,  not  that 
its  production  is  not  coustant,  but  that  it  accumulates  in  the  vagina 
and  escapes  a  little  at  a  time.  In  some  cases  there  appear  to  be  secre- 
tory crises,  when  a  great  quantity  of  fluid  is  discharged  all  at  once 
after  a  strong  pain;  this  suggests  the  intermitting  discharge  of  a 
dropsical  tube  (hydrops  tubse  profluens).  But  I  have  observed  in 
many  cases  that  this  flow  by  jets  may  be  present  where  there  is  no 
tubal  collection;  properly  speaking,  it  is  a  phenomenon  of  reflex 
pathological  hypersecretion. 

Certain  authors  have  sought  for  a  method  of  diagnosis  between 
leucorrhoea  of  the  vagina  and  that  from  the  uterus.  Schultze 5  has 
proposed  to  introduce  a  tampon  of  cotton  into  the  vagina  and  leave  it 
in  contact  with  the  cervix  during  twenty-four  hours ;  then,  on  remov- 
ing it,  one  can  judge  from  the  quality  of  the  absorbed  fluid  whether 
it  is  from  the  body  or  the  cervix. 

Leucorrhoea  may  depend  simply  on  a  general  debilitated  condition, 
as  anaemia,  chlorosis,  etc.     This  symptomatic  form  is  so  frequent  that 


172  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

Marc  d'Espine 6  lias  claimed  to  find  it  in  two-thirds  of  all  women. 
Many  workwomen  in  Paris  have  a  lencorrhceal  discharge,  and  explain 
it  by  the  fact  that  they  are  accustomed  to  drink  cafe-au-lait,  and 
there  are  physicians  who  are  able  to  gravely  accept  this  grotesque 
explanation.  Perhaps  it  is  true  that  because  they  are  able  to  take  no 
better  nourishment,  certain  women  have  the  whites.7 

Metrorrhagia,  Dysmenorrhea. — Menstrual  troubles  may  occur 
with  uterine  disease,  but  it  must  not  be  supposed  that  they  are  con- 
stant. Dysmenorrhea,  or  painful  menstruation,  is  often  observed  in 
metritis  from  the  same  mechanical  obstacle  to  the  flow  which  induces 
the  inflammation  (flexion,  narrowness  of  the  cervix,  etc.).  Amenor- 
rhcea  is  chiefly  due  to  anaemia;  for  though  metritis  which  has  lasted 
a  long  time  may  debilitate  the  patient,  still  its  influence  is  indirect. 

Metrorrhagia,  on  the  contrary,  is  directly  dependent  on  the  uterine 
inflammation,  and  is  most  often  seen  when  the  mucous  membrane  of 
the  body  is  affected  in  interstitial  metritis  (either  primarily  or  follow- 
ing fibroma  and  carcinoma),  the  loss  occurring  during  the  regular 
periods  or  at  other  times.  In  the  first  case  we  speak  of  it  as  menor- 
rhagia,  in  the  second  as  metrorrhagia. 

Most  of  the  uterine  diseases  are  an  obstacle  to  conception ;  but  the 
sterility  is  not  absolute,  for  pregnancy  may  occur  with  cancer  and 
fibroma,  and  the  same  is  true  of  metritis.  But  abortion  is  frequent  in 
these  diseases. 

Symptoms  from  Adjacent  Organs  and  Reflexes. — Ai^art  from 
pressure  effects,  which  do  not  enter  into  this  general  description,  or 
properly  belong  to  metritis,  there  are  always  symptoms  from  adjacent 
organs  in  all  affections  of  the  uterus.  Patients  complain  of  pain  in 
urination,  frequent  micturition,  or  it  may  be  of  vesical  tenesmus. 
Every  disease  of  the  uterus  affects  the  bladder  more  or  less,  and  yet 
the  patient  may  not  call  the  attention  of  the  physician  to  the  vesical 
disturbance.  When  it  is  necessary  to  use  a  catheter,  cystitis  may 
follow  if  antiseptic  precautions  are  not  observed. 

Since  patients  avoid  going  to  the  water-closet,  on  account  of  the 
efforts  involved  and  consequent  pressure  on  the  uterus,  they  defecate 
as  little  as  possible  and  become  habitually  constipated. 

Uterine  Dyspepsia. — There  is  no  function  upon  which  uterine 
disease  reflects  more  constantly  than  on  the  digestive,  and  ignorance 
of  this  fact  may  cause  grave  errors  of  diagnosis.  Such  a- dyspepsia  is 
explained  by  reflex  action  from  the  nervous  system  ;  to  understand 
it,  the  peculiar  richness  of  the  sympathetic  innervation  of  the  uterus 


SYMPTOMS,    COURSE,    AND    DIAGNOSIS    OF   METRITIS.  178 

and  stomach  need  only  be  recalled  to  mind.  Dilatation  of  the  stom- 
ach is  very  common  in  metritis  of  long  duration,  with  all  its 
train  of  symptoms  so  well  described  by  Bouchard  and  his  pupils.8 
The  subject  deserves  renewed  study,  for  dilatation  from  uterine  cause 
has  not  as  yet  been  thoroughly  described;  I  have  already  collected  a 
number  of  observations  upon  it.  But  to  dyspepsia,  or  inactive  diges- 
tion, the  attention  of  gynaecologists  has  for  a  long  time  been  directed, 
though  their  descriptions  are  but  brief;  Bennet  and  Courty 
have  mentioned  it  without  insisting  upon  it.  More  recently  import- 
ant memoirs  have  appeared  upon  the  subject.9  These  patients  surfer 
from  loss  of  appetite,  nausea,  and  a  peculiar  form  of  flatulence,  which 
occurs  as  a  chronic  tyurpanites,  so  that  the  abdomen  enlarges  till  the 
end  of  the  disease,  however  much  the  patient  may  have  lost  flesh. 
This  meteorism  is  very  troublesome  and  interferes  with  abdominal 
palpation  and  bimanual  exploration. 

Respiratory  Reflexes,  Uterine  Cough. — Patients  with  uterine 
disease  very  frequently  have  a  dry  cough,  occurring  singly  or  five 
at  a  time,  even  though  there  may  be  no  trace  of  disease  in  the 
respiratory  tract  and  the  hysterical  element  can  be  eliminated.  It 
is  generally  a  small  choking  cough,  but  may  be  so  metallic  and  sonor- 
ous that  both  the  patient  and  her  friends  are  alarmed.  Aran 10  has 
described  this  briefly;  one  of  my  pupils  has  devoted  to  it  a  more  com- 
plete study.11  Its  peculiarity  is  that  there  is  no  auscultatory  symp- 
tom, and  that  it  disappears  with  the  uterine  lesion — displacement, 
metritis,  etc. 

Symptoms  Referable  to  the  Central  and  Peripheral 
Nervous  System. 

Neuroses  and  Neuralgias  of  Genital  Origin. — We  can  explain 
the  pathogeny  of  these  reflexes  by  the  richness  of  the  innervation 
of  the  genital  organs,  which  are  supplied  from  the  great  sympa- 
thetic through  the  hypogastric  plexus,  and  from  the  cord  through  the 
internal  pubic  (Fig.  112).  Neuralgia  is  very  common.  Intercostal 
neuralgia  is  so  constant  that  Bassereau  claimed  that  it  was  always 
connected  with  metritis.  We  find  also  facial  neuralgia,  and  lumbo- 
abdominal  with  radiation  of  the  pain  along  the  cutaneous  femoral 
branches,  particularly  down  the  left  thigh. 

Simpson  and  Scanzoni12  have  insisted  upon  sacral  neuralgia, 
which,  they  have  made  the  subject  of  monographs  under  the  name  of 
coccygodynia.     An  attempt  has  been  made  to  refer  peripheral  neu- 


174 


CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 


roses  to  the  sensory  nerves.  Clifton  S.  Morse  describes  a  form  of 
asthenopia  dependent  upon  uterine  disease.13 

Lastly  I  may  mention' cardiac  palpitation,  both  reflex  and  due  to 
anaemia. 

I  will  not  insist  upon  the  general  nervous  troubles,  which  are  of 
great  diversity.  The  nervous  symptoms  cover  all  the  forms  of  hys- 
teria; not  that  we  have  a  veritable  hysteria,  though  it  may  rarely  be 
present,  but  that  "  alterations  of  the  nervous  system,  in  women,  almost 


Fig.  112.— Genital  Nerves  of  the  Infant.    Right  side,    a,  Right  cceliac  ganglion;  b,  first,  second, 
and  third  lumbar  ganglia;  c,  sacral  ganglion;  d,  cervical  ganglion;  e,  renal  ganglia;  /,  hypogastric  plexus. 


always  take  this  form,  especially  where  the  uterus  is  the  point  of 
departure  "  (Courty). 

It  is  certain  also  that  any  genital  disease  in  a  woman  predisposed 
to  hysteria  will  produce  a  development  of  that  neurosis ;  thus  we  can 
explain  both  the  intensity  of  the  symptoms  caused  by  slight  ailments, 
like  Emmet's  "  cicatricial  plug,"  and  the  marvellous  success  of  certain 
operations.  How  can  we  defend  the  diagnosis  of  hysteria  when  we 
read  observations  like  that  of  Munde,14  of  an  attack  of  sciatica  or 
catalepsy  produced  simply  by  pressure  upon  the  cicatrix  of  a  lacera- 


SYMPTOMS,    COURSE,   AND   DIAGNOSIS    OF   METRITIS.  175 

tion,  all  such  attacks  disappearing  after  operation  ?  One  might  al- 
most believe  in  a  special  pathology  for  the  hysterical,  and  special 
chances  of  successful  treatment,  and  expect  unhoped-for  results 
with  means  which  remain  useless  where  the  nervous  system  is  not 
hypersensitive. 

There  is  another  consequence  of  uterine  disease  which  is  often  seen 
with  metritis,  displacement,  etc.,  which  may  last  through  many  years. 
This  is  a  peculiar  asthenia,  an  excessive  depression  of  the  nervous 
system  which  renders  the  patient  incapable  of  all  effort,  although 
there  is  no  loss  of  muscular  strength  or  other  deviation  from  health 
corresponding  to  this  languor.  This  must  certainly  be  attributed  to 
morbid  reflex  action.13 

Finally  we  shall  see,  in  studying  displacements  of  the  uterus  and 
diseases  of  the  adnexa,  that  there  are  grave  nervous  troubles  present 
at  times,  like  chorea,  epilepsy,  etc.,  which  depend  directly  upon  them 
and  which  are  curable  at  the  same  time. 

General  Condition. — The  pain  which  prevents  exercise,  the  dys- 
IDepsia  which  impairs  alimentation,  the  condition  of  the  nervous  sys- 
tem which  has  a  depressing  influence  upon  nutrition,  all  combine  to 
alter  the  patient's  general  health  rapidly,  to  give  her  a  habitual 
chloro-ansemic  color,  a  muddy  complexion,  dark  circles  under  the  eyes, 
and  the  air  of  suffering,  which  together  complete  the  picture  of  the 
facies  uterina. 

It  is  this  combination  of  rational  signs  which  makes  up  the  syn- 
droms common  to  all  diseases  of  the  internal  genital  organs,  but 
which  is  most  marked  in  cases  of  metritis.  The  study  of  the  physical 
signs,  revealed  by  direct  examination,  permits  now  the  precise  state- 
ment of  the  characters  proper  to  uterine  inflammation. 

Physical  Signs. — By  touch,  which  should  always  be  practised 
with  bimanual  palpation,  we  find  the  cervix  increased  in  volume  and 
altered  in  consistence,  except  in  those  rare  cases  where  the  body  alone 
is  involved.  It  is  larger  and  more  open  than  normal,  with  a  velvety 
or  greasy  feel  when  its  surface  is  ulcerated;  and  in  places  there  is  the 
sensation  of  a  number  of  little  hard  grains,  which  are  glandular  cysts. 
The  finger  discovers,  moreover,  the  lacerations  upon  which  I  have 
dwelt  in  the  section  on  pathology.  By  pressing  upon  the  cervix,  at 
the  level  of  the  external  os  or  at  the  bottom  of  the  tear,  a  severe  pain 
is  provoked,  which  may  be  of  an  acute  neuralgic  character.  If  this 
examination  is  not  painful,  the  ballottement  of  the  uterus,  performed 
by  giving  a  rocking  motion  to  the  cervix,  hurts  severely,  and  Gosselin 1 


176  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

lays  much  stress  upon  the  clinical  importance  of  the  fact.  Touch  also 
informs  us  whether  the  cul-de-sac  is  free;  the  uterus  being  then  per- 
fectly movable. 

The  first  examination  with  the  speculum  should  be  made  by  pref- 
erence with  Brewer's  bivalve  or  with  two  single  blades  of  Simon,  in 
the  lithotomy  position.  It  discloses  a  very  large  cervix,  of  altered 
form,  which  at  times  tills  the  depths  of  the  vagina:  in  nulliparae,  in- 
stead of  being  conical,  as  it  should  be,  it  is  cylindrical ;  in  a  woman 
who  has  had  children,  it  is  often  swollen,  and  if  there  has  been  a  lacer- 
ation, it  may  be  peculiarly  figured  and  of  various  forms.  The  color 
varies  between  bright  red  and  violet.  A  discharge  of  viscid  mucus, 
at  times  very  purulent  or  mixed  Avith  bloody  threads,  escapes  from 
the  cervix;  by  the  repeated  gentle  pressure  of  the  speculum  it  seems 
to  be  milked  from  the  organ.  The  surface  of  the  part  presents  an 
eroded  aspect,  the  apparent  loss  of  substance  being  at  times  small 
and  disseminated  over  the  surface  (the  folliculitis  of  authors),  resem- 
bling a  slight  vesication  (erosion),  or  deep,  smooth  and  polished,  or 
granular  (ulceration) ;  at  times  yellowish  grains  indicate  the  superficial 
cysts  called  ISTaboth's  ovules.  Lacerations  are  often  less  perceptible 
to  the  sight  at  the  bottom  of  the  speculum  thai?  to  the  touch,  and  the 
ulcerated  surface  is  far  less  displayed  by  a  cylindrical  speculum  than 
by  a  bivalve. 

To  separate  the  lips,  and  see  into  the  cavity  of  the  cervix,  one  can 
use  Courty's  forceps  or  two  tenacula.  Rectal  is  a  useful  addition  to 
vaginal  touch,  but  it  may  be  negative  in  simple  metritis. 

The  use  of  the  uterine  sound  demonstrates  in  most  cases  an  in- 
crease in  the  depth  of  the  uterine  cavity  which  may  reach  as  high  as 
8  cm.  (3t§-  in.).  When  the  sound  passes  deeply  in,  there  may  be  another 
explanation  for  it  than  metritis.  When  the  uterus  is  displaced  to 
one  side  (which  often  happens  in  deep  laceration,  where  it  is  bent 
toward  the  torn  side),  the  sound  does  not  measure  the  exact  height  of 
the  organ,  but  that  of  a  line  obliquely  directed  toward  the  cornu  oppo- 
site the  side  to  which  the  uterus  is  bent— thus  there  is  an  apparent 
elongation  which  does  not  really  exist.  To  rectify  the  error  when 
there  is  reason  to  suspect  its  presence,  the  uterus  can  be  raised  by  bi- 
manual palpation  or  the  patient  may  be  placed  in  the  genu-pectoral 
position,  which  straightens  the  uterus  considerably. 

The  sound  often  causes  pain,  but  it  is  an  exaggeration  to  say  with 
Veit  that  one  can  thus  determine  the  exact  point  where  the  inflam- 
mation is  most  marked.     In  reality  it  is  often  the  movement  of  the 


SYMPTOMS,    COURSE,    AND    DIAGNOSIS    OF   METRITIS.  177 

organ  as  a  whole,  rather  than  the  friction  of  the  mncons  membrane 
that  causes  the  pain.  The  escape  of  blood  as  soon  as  the  sound  has 
passed  is  a  sure  indication  of  altered  mucous  membrane :  if  there  are 
f ungosities  present,  they  can  usually  be  felt  by  the  sound. 

The  Different  Forms  of  Metritis. 

Acute  Form. — At  the  beginning  of  a  metritis  there  is  often  a  chill 
with  fever.  Such  acute  phenomena  are  at  times  present  in  the  course 
of  a  chronic  metritis  as  the  result  of  some  special  fatigue  or  at  the 
menstrual  epoch.  However,  it  may  be,  when  the  metritis  takes  this 
form  either  acutely  or  gradually,  direct  exploration  reveals  the 
peculiar  sensitiveness  of  the  organ,  the  heat  of  the  vagina,  where  the 
finger  perceives  a  throbbing  at  times,  the  redness  and  swelling  of 
the  external  os — in  one  word,  all  the  classic  signs  of  inflammation. 
They  usually  disappear  very  quickly,  but  may  return  if  there  is  a 
renewal  of  the  cause. 

Catarrhal  Form. — In  this  form  two  features  predominate,  namely, 
the  erosion  of  the  cervix  and  the  leucorrhceal  discharge.  I  have 
already  described  the  appearance  of  the  eroded  cervix  and  do  not 
need  to  repeat  it. 

This  form  is  observed  most  often  in  young  women  and  is  accom- 
panied with  reflex  nervous  symptoms  (palpitation,  dyspepsia,  etc.) 
which  I  have  already  enumerated.  The  principal  portion  involved  is 
the  region  of  the  cervix;  it  is  the  cervical  catarrh  of  authors.  I  believe 
it  a  mistake  to  describe  it  as  a  circumscribed  lesion,  for  there  is 
always  a  concomitant  alteration  in  the  mucous  membrane  of  the  uter- 
ine body,  and  in  therapeutics  of  the  part  this  must  not  be  neglected, 
or  our  treatment  will  disappoint  us. 

Hemorrhagic  Form. — Here,  on  the  contrary,  it  is  the  uterine  body 
which  especially  suffers,  while  the  cervix  may  remain  comparatively 
healthy.  We  meet  with  this  form  chiefly  in  young  girls  at  the  estab- 
lishment of  menstruation  and  in  women  near  the  menopause;  it  is 
also  the  form  most  common  after  abortion,  when  the  almost  invisible 
particles  of  the  decidua  graft  themselves  on  the  mucosa  and  set  up 
a  lasting  inflammation.  Early  abortions  are  often  unrecognized  and 
their  pathogenic  influence  is  felt  more  frequently  than  is  supposed. 

In  the  catarrhal  and  hemorrhagic  forms  which  have  lasted  a  long 

time,  we  observe  those  profound  alterations  of  the  mucous  membrane 

of  a  vegetating,  fungous  nature  which  we  call  polypi.     This  exuber- 
12 


178  CLINICAL   AND   OPEEATIVE   GYNAECOLOGY. 

ant  prolif  eration  of  tlie  interstitial  and  glandular  elements  may  also 
be  found  on  the  cervix ;  it  then  appears  externally  and  constitutes  a 
new  symptom,  but  that  fact  does  not  warrant  us  in  giving  the  affec- 
tion.a  new  name.  Mucous  polypi  and  follicular  hypertrophy  of  the 
cervix  are  lesions  of  metritis  and  should  be  described  with  it  both 
anatomically  and  clinically.  I  have  already  described  their  histologi- 
cal nature  above.  The  appearance  of  these  polypi  recalls  that  of  the 
nasal  variety ;  they  are  red  or  violet  in  color,  of  the  size  of  a  hazel- 
nut, sometimes  furnished  with  a  pedicle,  sometimes  sessile.  It  is  easy 
to  recognize  them  by  touch  or  speculum. 

Follicular  hypertrophy  of  the  cervix  is  due  to  a  glandular  vegeta- 
tion in  the  thickness  of  one  of  the  lips,  which  thus  presents  a  hyper- 
trophic elongation  and  a  soft  consistence,  is  marked  by  many  fissures, 
and  can  be  brought  down  to  the  vulvar  orifice. 

The  polypi  give  rise  to  frequent  serious  bleeding;  the  elongation 
is  an  accompaniment  of  the  catarrh. 

The  hemorrhagic  form  may  cause  almost  continual  losses  through 
many  months,  with  very  short  intervals ;  some  women  are  thus  brought 
to  an  extreme  degree  of  anaemia.  The  discharge  of  the  blood  occurs 
most  often  without  colic ;  the  patients  complain  only  of  more  or  less 
intense  lumbar  pain,  and  present  various  neuralgic  points. 

Chronic  Painful  Form  {Chronic  Metritis,  Engorgement,  Uterine 
Infarction). — I  have  called  this  the  painful  form,  for  the  pain  and  its 
consequent  weakness  are  the  chief  features. 

It  is  absolutely  false  to  represent  chronic  metritis  as  the  sequel 
and  residue  of  an  acute  attack.  It  is  far  more  correct  to  say  that  it  is 
the  result  of  an  infection  which  has  developed  slowly,  slumbering  a 
long  time  after  the  infecting  cause  has  disappeared ;  a  state  of  things 
which  Verneuil  has  described  as  latent  microbism.16  Such  a  case  has 
an  insidious  course,  deceiving  respites,  and  unnoticed  exacerbations ; 
so  that  there  are  many  points  in  an  old  focus  of  osteitis  which  clin- 
ically resemble  a  case  of  chronic  metritis,  for  in  the  intervals  between 
exacerbations,  both  the  one  and  the  other  are  more  of  an  infirmity 
than  a  disease. 

Sometimes  the  case  is  one  of  localized  puerperal  infection,  of  a 
very  slow  course.  The  delay  in  the  normal  involution,  the  engorge- 
ment as  certain  authors  say,  is  characterized  by  an  abnormal  volume 
of  the  uterus,  a  feeling  of  weight,  pain  in  the  loins,  discomfort  in 
standing  or  walking,  and  dysmenorrhcea.  These  first  symptoms  may 
be  unnoticed  during  the  early  months;  the  woman  merely  feels  ill 


SYMPTOMS,    COUBSE,   AND   DIAGNOSIS    OF   METRITIS.  179 

after  some  unusual  fatigue,  attributes  to  this  cause  all  her  trouble, 
and  forgets  the  already  distant  labor  or  abortion.  Later  on  the  pain 
becomes  more  severe,  and  enforces  more  or  less  complete  repose.  The 
local  examination  reveals  a  different  condition  according  as  it  is  made 
during  the  exacerbations  or  at  other  times.  In  the  former  case  we 
have  the  signs  already  described  with  acute  metritis.  At  other  times 
we  tind  the  cervix  somewhat  swollen,  hard,  perhaps  sclerosed,  often  of 
very  irregular  form,  due  to  old  lacerations,  of  an  almost  wooden  con- 
sistence in  places,  and  at  other  points  feeling  as  if  covered  with  small 
nodosities  like  grains  of  shot  (glandular  cysts).  The  speculum  dis- 
closes this  granular  appearance  and  a  variable  congestion  which  often 
has  a  very  characteristic  coppery  look.  If  there  are  lacerations,  one 
can  observe  the  ectropion  of  the  mucous  membrane,  but  there  is  sel- 
dom any  such  f ungosity  of  the  ulcerated  surface  as  in  the  catarrhal 
form;  it  is  far  more  likely  to  be  smooth  as  in  a  cicatrizing  ulcer. 
Touch  often  reveals  an  accompanying  displacement;  but  the  sound 
does  not  give  any  marked  increase  in  the  depth  of  the  organ. 

There  is  one  variety  of  chronic  painful  metritis  which  deserves  a 
special  description ;  it  is  that  which  passes  under  the  name  of  mem- 
branous dysmenorrhcea,  exfoliating  endometritis,  or  decidua  men- 
strualis.  The  capital  symptom  is  the  painful  extrusion  at  the  men- 
strual period  of  all  or  a  part  of  the  uterine  mucous  membrane ;  this 
presents  the  histological  alterations  of  acute  inflammation  (acute 
endometritis,  Fig.  96).  These  patients  may  suffer  very  little  between 
their  periods,  though  indubitable  signs  of  metritis  are  present,  such 
as  leucorrhcea.  Many  authors,  however,  have  overlooked  this  source 
of  the  disease  and  made  it  a  distinct  variety  of  metritis.  Others,  as 
Schroeder,  have  seen  the  relation:  he  says  in  one  place,  "chronic 
catarrh  is  found  so  often  that  it  may  be  considered  as  the  cause  of  the 
disease." 17  If  the  origin  of  the  affection  be  sought,  we  find  almost 
always  that  it  followed  labor  or  abortion,  more  rarely  that  it  appeared 
at  the  establishment  of  menstruation  (the  importance  of  these  phases 
of  the  genital  life  in  the  development  of  metritis  is  well  known). 
This  disease  may  then  be  described  as  a  chronic  metritis  with  acute 
exacerbations  and  inflammatory  desquamation  of  the  mucous  mem- 
brane at  the  time  of  the  regular  period.  Therefore  it  enters  clinically 
into  the  chronic  form,  and  anatomically  belongs  to  the  acute.  At 
times  the  membrane  is  passed  in  shreds;  at  other  times  the  sac  is 
complete,  and  the  form  of  the  uterine  cavity  can  be  recognized,  the 
internal  surface  being  grooved  in  little  furrows,  the  external  being 


180  CLINICAL   AND    OPERATIVE   GYNECOLOGY. 

irregular  and  jagged.  This  membrane  must  not  be  confounded  with 
the  product  of  an  abortion,  where  an  attentive  examination  (especially 
after  short  immersion  in  picric  acid)  reveals  the  chorionic  villi.18  On 
the  other  hand,  the  presence  or  absence  of  cells  of  the  decidua  is  not 
pathognomonic.19 

This  special  manifestation  of  chronic  metritis  lasts  until  the  meno- 
pause, unless  energetic  treatment  is  begun ;  it  may  accompany  men- 
orrhagia.  Although  it  usually  produces  sterility,  pregnancy  may  oc- 
cur, with  a  return  of  the  disease  after  labor. 

Course,  Prognosis. — All  the  forms  of  metritis  are  rebellious;  the 
mucous  membrane,  the  muscular  tissue,  the  parenchyma,  become 
involved  in  turn;  then  follow  uterine  sclerosis,  cyst-formation,  etc. 
Sometimes  the  sequel  is  the  morbid  condition  which  we  know  as 
chronic  metritis,  for  every  case  which  is  not  rapidly  cured  tends  to 
become  chronic.  Scanzoni  asserts  that  he  has  never  seen  a  case  of 
chronic  metritis  cured,  but  he  does  not  distinguish  clearly  enough 
between  that  and  salpingitis. 

Does  metritis  predispose  to  cancer  ?  We  have  seen  that  a  number 
of  foreign  authors  do  not  hesitate  to  say  that  the  combination  of  cer- 
vical catarrh  and  a  laceration  offers  favorable  conditions  for  the  ap- 
pearance of  carcinoma  (epithelioma).  An  inflammation  of  the  mucous 
membrane  of  long  duration,  when  it  takes  the  glandular  form,  may 
lead  to  the  formation  of  adenoma;  now,  when  the  epithelial  vegeta- 
tion passes  the  limit  of  the  cul-de-sac,  the  typical  adenoma  becomes 
atypical,  and  by  a  progressive  transition,  an  actual  cancer  of  the  cer- 
vix is  produced. 

Diagnosis. — The  causes  of  error  may  come  from  exaggeration  of 
one  symptom,  or  from  neglect  of  concomitant  signs. 

The  increase  in  size  alone,  or  with  the  dyspeptic  symptoms,  may 
simulate  beginning  pregnancy,  especially  if  there  is  amenorrhea;  the 
question  can  be  determined  by  waiting  or  by  the  various  explora- 
tory methods. 

The  abundance  of  the  leucorrhcea  with  the  cervical  laceration  may 
give  the  idea  of  cancer;  the  characters  of  the  one  and  the  other  are, 
however,  very  different:  in  cancer  the  discharge  is  not  muco-purulent 
and  viscid,  but  serous,  of  a  reddish  color,  having  a  peculiar  stale 
smell:  the  ulceration  is  seamed,  sown  with  yellow  points,  and  bounded 
by  hard  borders  when  it  is  not  of  a  cauliflower  form:  it  destroys  the 
supporting  tissues  so  that  there  is  a  marked  loss  of  substance,  which 
is  never  found  in  the  pseudo-ulceration  of  metritis.     The  hard  and 


SYMPTOMS,   COURSE,   AXD   DIAGNOSIS   OF   METRITIS.  181 

nodular  swelling  of  the  cervix,  clue  to  the  development  of  sclerosis  and 
cysts  together,  gives  to  the  linger  the  feeling  of  cancer,  it  is  true ;  but 
puncture  of  the  cysts  and  incision  of  the  cervix  to  remove  the  conges- 
tion will  make  the  diagnosis  very  clear.  If  necessary,  a  small  section 
may  be  cut  from  the  part  and  examined  by  the  microscope. 

Strong  regular  pains,  a  very  tenacious  discharge  of  fetid  muco-pus 
mixed  with  blood,  a  great  increase  in  the  size  of  the  organ,  and  the 
examination  of  pieces  removed  by  the  curette,  confirm  the  diagnosis 
of  carcinoma  of  the  uterine  body. 

The  metrorrhagia  produced  by  an  early  abortion  must  not  be  con- 
founded with  hemorrhagic  metritis ;  the  study  of  the  matters  expelled 
and  the  patient's  antecedents  should  enable  us  to  decide. 

Fibrinous  polypi,  or  better  placental,  are  nothing  but  the  debris 20 
of  the  placenta  or  chorionic  villi  which  have  remained  planted  upon 
the  uterine  mucous  membrane,  and  which  may  continue  their  obscure 
life  there  through  many  weeks  or  even  months 21  after  labor  or  abor- 
tion. The  patient's  own  story,  and  the  examination  of  pieces  scraped 
away  with  the  blunt  curette,  will  soon  show  what  is  the  origin  of  the 
little  tumor. 

Fibrous  polypi,  if  intra-uterine,  may  give  rise  to  a  symptom-com- 
plex like  that  of  metritis  with  abundant  hemorrhage.  Examination 
by  bimanual  palpation,  the  uterine  sound,  and,  if  necessary,  dilata- 
tion of  the  cervix,  should  prevent  error  here. 

Salpingitis,  as  I  have  said,  often  coexists  with  metritis.  The  diag- 
nosis consists  in  deciding  which  of  the  two  lesions  predominates,  and 
gives,  therefore,  its  character  to  the  malady.  Bimanual  palpation,  per- 
haps with  the  aid  of  anaesthesia,  should  be  employed  to  discover  the 
condition  of  the  adnexa.  If  they  are  not  augmented  in  volume  but 
only  a  little  painful  on  palpation,  while  the  uterus  presents  the  ob- 
jective signs  which  I  have  described,  the  diagnosis  is  clearly  metritis. 

I  have  described  the  existence  of  metritis  symptomatic  of  primitive 
and  non-inflammatory  disease  of  the  adnexa ;  by  that  I  mean  that  a 
lesion  of  a  tube,  an  ovary,  or  a  broad  ligament  may  be  reflected  in  the 
uterus.22  It  is  difficult  to  say  in  what  way  the  uterine  mucous  mem- 
brane becomes  affected,  but  we  cannot  deny  that  it  does  alter.  A 
small  ovarian  tumor  has  been  the  starting-point  for  profuse  bleeding, 
with  hyperplastic  endometritis  which  was  confirmed  by  autopsy. 
Brennecke23  and  Lohlein,24  who  reported  cases  of  this  kind,  thought 
that  reflex  hyperemia  caused  by  the  ovarian  irritation  was  suffi- 
cient to  produce  the  mucous  hyperplasia.     It  must  be  acknowledged 


182  CLINICAL   A1STD    OPERATIVE   GYNAECOLOGY. 

that  this  state  of  permanent  congestion  creates  a  peculiar  morbid 
receptivity,  owing  to  which  the  numerous  causes  of  infection — 
germs  dwelling  within  the  vagina  and  germs  from  without — are  able 
to  exercise  their  evil  influence  and  overcome  an  organization  already 
enfeebled  by  inflammation. 

As  regards  diagnosis,  there  are  two  well-established  facts  which 
the  clinician  must  not  forget : 

1.  There  is  but  a  narrow  limit  between  inflammations  of  the  uterus 
and  of  the  adnexa;  we  should  always  seek  for  the  latter,  therefore, 
because  whether  it  be  protopathic  or  deuteropathic,  its  existence  may 
become  very  important  in  consideration  of  operative  interference. 

2.  Alterations  in  the  ovaries,  whether  inflammatory  or  not,  may 
simulate  metritis  by  their  reflection  upon  the  uterine  mucous  mem- 
brane; the  alteration,  at  first  simply  congestive,  tends  to  transform 
itself  into  a  veritable  inflammatory  lesion. 

Cystitis  may  occur  with  inflammation  of  the  uterus  or  resemble  it 
by  the  pain  which  it  causes.  The  same  is  true  of  proctitis  with  tenes- 
mus and  a  glairy  secretion  (anal  leucorrhoea),  which  we  see  at  times 
appearing  with  an  acute  metritis  with  which  it  is  connected.  In  such 
a  case  we  must  be  careful  not  to  see  the  effect  and  overlook  the  cause. 
I  have  seen  a  sphincteralgia  in  one  case,  which  yielded  to  the  cure  of 
a  catarrhal  metritis.  Very  exceptionally  a  rectal  disease  provokes 
symptoms  of  pseudo -metritis.  I  have  published 25  a  case  of  rectal 
polypus  which  for  a  long  time  gave  rise  to  signs  which  were  thought 
to  be  due  to  metritis.  Rectal  touch  enabled  me  to  discover  the  cause 
of  the  disease  and  cure  it  by  removal  of  the  polypus ;  the  patient  had 
mistaken  for  metrorrhagia  a  bloody  discharge  which  really  came 
from  the  rectum. 

The  disturbance  of  the  general  health  is  often  so  severe  that  it  en- 
tirely masks  the  local  lesion.  The  patient  may  complain  of  persistent 
cough,  or  loss  of  breath,  or  progressive  emaciation,  and  say  little  about 
her  leucorrhoea  and  abdominal  pain.  One  is  often  inclined  to  think 
of  pulmonary  tuberculosis  until  auscultation  reveals  the  error.  With 
other  cases  it  is  the  symptoms  referable  to  the  stomach  which  pre- 
dominate; loss  of  appetite,  flatulence,  gurgling,  with  percussion  and 
succussion,  demonstrate  the  existence  of  dilatation  of  the  stomach. 
It  is  present,  but  is  only  symptomatic  of  a  metritis  of  which  it  is  a 
sequence.  Finally  the  number  of  young  women  who  suffer  from  pre- 
cordial anxiety,  palpitation,  and  in  whom  the  stethoscope  reveals 
cardiac  and  vascular   murmurs,   is   very  large;    on    examining   the 


SYMPTOMS,   COURSE,   AND   DIAGNOSIS   OF   METRITIS.  183 

uterus  also,  we  very  quickly  recognize  that  we  have  to   deal  with   a 
metritis  or,  less  probably,  with  a  lesion  of  the  adnexa. 

The  rule  should  be,  therefore,  to  carefully  examine  the  uterus  in 
every  woman  with  a  chronic  disease. 

BIBLIOGRAPHY. 

1.  Gosselin  :   Clinique  Chirurg.  de  FHopital  de  la  Charity,  1879,  vol.  iii.,  p.  33. 

2.  J.  B.  Blatin  :  Du  Catarrhe  Uterin  et  des  Flueurs  Blanches,  Paris,  an  X.,  1801. 

3.  Courty  :   Loc.  eit,,  p.  942. 

4.  O.  Kiistner  :    Beitrage  zur  Lehre  von  der  Endometritis,  Jan.,  1883,  p.  87. 

5.  Schultze  :  Der  Probetampon,  ein  Mittel  zur  Erkennung  der  kronischen 
Endometritis.     Centr.  f.  Gyn.,  1880. 

6.  Marc  d'Espine  :  Recherches  Anatomiques  sur  quelques  Points  de  l'Histoire 
de  la  Leucorrhoea.     Arch.  g<5n.  de  He'd.,  1836,  page  165. 

7.  Lagreau  :  Diet,  in  20  vols.,  art.  Leucorrhoea,  Paris,  1848.  Lisfranc  :  Clinique 
Chirurg.  de  la  Pitie\  vol.  ii.,  page  300,  Paris,  1842.  Nonat :  Traite  Prat,  des  Mai. 
de  1' Uterus,  page  634. 

8.  Legendre  :  These  de  Paris,  1886. 

9.  G.  Braun  :  Wiener  med.  Woch.,  41-42, 1886.  Imlach  :  On  Uterine  Dyspepsia. 
British  Gyngec.  Journal,  February,  1887. 

10.  Aran  :   Lecons  Cliniques  sur  les  Maladies  de  FUt£rus,  Paris,  1858. 

11.  P.  Miiller  :   De  la  Toux  Uterine.     These  de  Paris,  1887. 

12.  Simpson  :'  Diseases  of  "Women,  Edinburgh,  1872,  page  202,  and  Scanzoni  : 
Krankh.  der  Weib.  Sexual-Org.,  ii.,  page  225. 

13.  C.  S.  Morse  :   New  York  Med.  Jour.,  Jan.  22d,  1887. 

14.  Monde" :   Minor  Surg.  Gyna;c.,  page  442. 

15.  Playfah* :  Note  on  the  Systematic  Treatment  of  Nerve-prostration  and 
Hysteria  Connected  with  Uterine  Disease.  Lancet,  1881.  Graily  Hewitt :  Rey- 
nolds1 System  of  Medicine,  vol.  v.,  p.  700.  John  Auld  :  Uterine  Dyskinesia.  Medi- 
cal and  Surgical  Reporter,  March  31st,  1883. 

16.  Verneuil :  Du  Parasitisme  Microbique  Latent.  Bull,  de  FAcad.  de  M6d., 
August  3d,  1886,  2d  series,  vol.  xvi.,  p.  105. 

17.  Schroeder  :  Mai.  des  Org.  Gen.,  French  ed.,  page  361. 

18.  De  Sinewy  :   Comptes  Rendus  de  la  Soc.  de  Biologie,  vol.  xxviii.,  1876. 

19.  Ruge  :  Zeitschr.  f.  Geb.  und  Gyn.,  vol.  v.,  1881. 

20.  Klasson:  Etude  sur  les  faux  Polypes  de  FUterus.  Ann.  de  Gynec.,  Feb., 
1889. 

21.  McLean:  Placenta  Retained  for  Nine  Weeks  after  Miscarriage  at  Three  and 
a  Half  Months.     Amer.  Jour.  Obst.,  Jan.,  1888. 

22.  Czempin  :  Ueber  die  Beziehungen  der  Uterusschleimhaut  zu  den  Erkran- 
kungen  der  Adnexa.     Zeitsch.  f.  Geb.  und  Gyn.,  Bd.  xii.,  2. 

23.  Brennecke  :  Zur  Aetiologie  der  Endometritis  fungosa.  Arch.  f.  Gyn.,  Bd. 
xx.,  p.  455. 

24.  Lohlein :  Ueber  einige  Formen  der  Endometritis  Corporis.  Berl.  klin. 
Woch.,  No.  23,  1886. 

25.  S.  Pozzi :  Ann.  de  Gyn.,  Nov.,  1884. 


*      CHAPTEE  TIL 
TKEATMENT   OF   METEITIS. 

The  prophylaxis  of  uterine  inflammation  made  a  great  step  for- 
ward when  antisepsis  was  lirst  followed  in  obstetrics.  It  is  to  a  more 
or  less  localized  and  attenuated  puerperal  infection  that  the  majority 
of  cases  of  metritis  are  due. 

The  complete  cleansing  of  the  uterine  cavity  after  labor  and  abor- 
tion of  all  debris  of  membranes  and  placenta  has  a  capital  importance 
here.  In  my  opinion,  the  discussion  whether  expectance  accom- 
plishes more  than  active  interference  is  all  wrong.  Budin *  has  raised 
his  voice  too  loudly  against  what  I  call  the  exaggerated  fear  of  acci- 
dent from  the  expectant  plan:  he  bases  his  ideas  upon  statistics  of  all 
cases  treated  in  the  maternity  service  of  la  Charite  during  a  period  of 
three  years,  comprising  46  retentions  in  210  cases  of  abortion:  did  he 
notice  that  septicaemia  occurred  but  four  times,  and  only  once  with  a 
fatal  issue  ? 

Budin  combats  hemorrhage  by  tampons,  septic  accidents  by  vaginal 
and  intra-uterine  injections  of  sublimate  (1 : 2,000  or  1 :  3,000)  or  car- 
bolic (20  or  30:1,000),  with  quinine  internally.  Surely  one  can,  no 
doubt,  thus  remove  the  immediate  trouble,  but  is  it  the  same  with  the 
sequels,  metritis  and  salpingitis?  As  surely  not!  Are  the  patients 
really  cured  who  have  escaped  from  death?  For  my  part  I  cannot 
combat  this  therapeutic  cowardice  enough.  If  there  is  reason  to  fear 
that  a  portion  of  the  foetal  structures  has  been  left  within  the  uterine 
cavity,  no  time  must  be  lost  before  making  exploration,  thorough 
cleansing,  and  disinfecting;  do  not  await  the  appearance  of  hemor- 
rhages, for  by  that  time  the  mucous  membrane  is  already  infected. 
The  dull  curette  of  Recamier,  and  weak  injections  of  sublimate,  are 
the  best  means  at  hand. 

After  thorough  use  of  the  curette,  followed  by  a  haemostatic  injec- 
tion of  perchloride  of  iron  and  antiseptic  irrigation,  the  temperature 
is  seen  to  fall  one  or  two  degrees  if  it  has  been  high  before;  one  can 
prevent  fever  and  insure  rapid  recovery  where  the  decomposition  of 


TREATMENT   OF   METRITIS. 


185 


the  debris  lias  not  yet  begun.  The  "  ecouvillon  "  (or  scraper)  which 
has  been  advocated  for  this  purpose,  is  an  altogether  unsuitable  in- 
strument, as  is  shown  by  a  case  ending  in  death,  published  by  one 
of  its  partisans.2  It  is  evident,  a  priori,  that  it  has  not  sufficient 
force  to  detach  by  scraping  the  often  firmly  adherent  debris. 

Before  mentioning  the  special  treatment  suited  to  each  case  I  will 
describe  the  therapy  which  is  applicable  to  all  alike. 

It  has  been  recommended  to  immobilize  the  abdomen  with  a  band- 
age of  ticking,  elastic  tissue,  or  a  band  of  flannel  making  two  turns 


Fig.  113.— Abdominal  Bandages.    A,  Of  elastic  stocking  tissue;  B,  of  webbing  for  stout  women  who 

do  not  stand  compression  well. 

round  the  body,  a  little  obliquely  from  above  downward;  this  affords 
much  comfort  in  walking. 

All  fatigue  and  all  violent  efforts  must  be  forbidden,  and  the  sexual 
relation  given  up. 

The  constipation  is  best  combated  by  means  of  proper  food  (vege- 
tables, Graham  bread,  prunes,  etc.),  mild  laxatives  (mineral  waters, 
rhubarb  and  magnesia,  etc.)  and  enemata,  to  which  we  can  add  a 
spoonful  of  glycerin.  Certain  patients  find  it  well  to  take  at  meals  a 
spoonful  of  white  mustard  in  water;  this  mechanically  provokes 
hypersecretion  and  contraction  of  the  intestine.  Long-continued  use 
of  drastic  purgatives,  like  aloes,  podophyllin,  etc.,  has  its  own  incon- 
veniences, but  we  have  to  employ  them  at  times.  It  is  very  import- 
ant to  unload  the  large  intestine  and  thus  relieve  the  pelvic  viscera. 

The  patient's  general  condition  must  be  kept  up  by  tonics  which 
are  suited  to  her;  for  women  who  are  of  a  lymphatic  temperament, 
cod-liver  oil  and  phosphates ;  for  the  arthritic,  preparations  of  arsenic ; 
for  almost  all,  iron,  with  quinine  and  rhubarb  may  be  administered 
with  success.  Lastly  hydrotherapy  is  a  powerful  auxiliary,  espe- 
cially where  the  metritis  has  produced  ansemia  and  nervous  symptoms, 
as  it  so  often  does. 

There  is    no  other  disease  where  mineral  waters  have  been   so 


186  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

strongly  recommended.  They  certainly  have  a  good  effect  on  the 
general  state,  and  indirectly  on  the  local.  I  think  that  the  chief  indi- 
cation is  to  take  care  of  the  patient's  general  condition  and  of  the 
reflex  disturbances  of  the  chief  organs  which  may  be  produced  by  the 
uterine  disease.  If  the  patient  is  very  anaemic,  we  prescribe  in  pref- 
erence ferruginous  waters,  or  sulphur  and  arsenical  with  sea-bathing: 
for  dyspeptics,  alkaline  waters  and  gentle  purgatives ;  for  the  nervous, 
indifferent  waters,  but  a  spa  which  is  pleasantly  situated,  and  on  high 
ground.  Finally,  springs  charged  with  chloride  of  sodium  have  an 
incontestable  action,  not  only  on  the  scrofulous  and  lymphatic  consti- 
tutions, but  also  on  all  visceral  congestion,  and  may  be  of  real  benefit 
in  the  beginning  of  certain  forms  of  chronic  metritis  where  the  en- 
gorgement of  the  body  predominates  without  great  alteration  in  the 
cervix. 

Special  Treatment  of  each  Form. 

In  acute  metritis  the  rest  in  bed  must  be  absolute:  sitz-baths  are 
prescribed  with  the  introduction,  while  in  the  bath,  of  a  small  specu- 
lum, which  allows  the  water  to  reach  the  cervix;  and  repeated  mild 


Fig.  114. — Bath  Speculum. 


purgatives  should  be  given.  If  the  pain  is  very  severe,  it  may  be 
calmed  by  laudanum  in  the  vaginal  douche  or  by  opium  suppositories. 
The  daily  application  of  a  glycerin  tampon,  which  is  left  in  place 
twelve  hours,  is  an  excellent  antiphlogistic ;  the  glycerin,  having  an 
affinity  for  water,  causes  considerable  flow  of  serum.  The  patient  can 
be  taught  how  to  introduce  the  tampon  herself,  with  the  aid  of  a 
cylindrical  speculum  which  she  guides  by  a  long  handle;  the  specu- 
lum is  then  withdrawn,  leaving  the  tampon  in  place. 

Hot  vaginal  douches  (45  to  50°  C.)  kept  up  for  a  long  time  are  of 
great  service.  This  therapeutic  measure,  advised  by  Sedillot  and 
Trousseau,  generalized  anew  by  Emmet  and  other  American  and  Eng- 
lish gynaecologists,  is  capable  of  many  applications,  but  it  is  well  to 
give  precise  directions  for  its  employment. 

The  injection,  or  better  the  irrigation  or  hot  douche,  should  be 


TREATMENT    OF    METRITIS. 


187 


taken  by  the  patient  lying  at  the  edge  of  the  bed,  her  legs  supported 
on  either  side  by  a  table  or  chair,  and  the  pelvis  a  little  elevated.  For 
greater  convenience  a  basin  or  a  piece  of  rubber  tissue  should  be 
placed  under  the  buttocks,  folded  along  the  edge  into  a  gutter  and 
leading  into  a  pail  below  (Fig.  5).  The  vessel  containing  the  water 
should  hold  not  less  than  three  litres  (Fig.  2) ;  it  is  filled  with  water 
at  45°  C.  (115  °  F.)  (there  is  always  a  loss  of  two  degrees  in  passing 
through  the  apparatus),  and  raised  about  one  metre  above  the  patient. 


Fig.  115.— Cervical,  Scarificators. 


The  vaginal  tube  is  then  gently  pushed  up  as  far  as  the  cervix.  It  is 
well  before  beginning  the  injection  to  cover  the  vulva  and  perineum 
with  vaselin ;  the  action  of  the  hot  water  is  then  less  disagreeable. 
From  three  to  ten  litres  may  be  used  at  one  time  and  the  douche  re- 
peated twice  a  day ;  after  each,  it  is  well  to  pass  two  fingers  into  the 
vagina  and  depress  the  f  ourchette  strongly  to  allow  the  escape  "of  the 
accumulated  water;  then  a  glycerin  tampon  may  be  introduced  and 
the  patient  ordered  to  rest  an  hour  in  bed.  That  the  acute  stage  may 
not  be  too  prolonged,  we  may  have  recourse  to  scarification — local 
blood-letting.  The  scarificator  (Fig.  115)  can  be  used  for  this  purpose, 
but  there  is  no  need  for  a  special  instrument.  An  ordinary  bistoury 
round  which  is  rolled  a  band  of  diachylon  that  leaves  only  about  one 
centimetre  of  the  blade  free,  will  do  as  well. 

After  the  vagina  has  been  well  irrigated,  a  cylindrical  speculum 
is  passed  in  and  the  cervix  displayed ;  then  it  is  pierced  in  a  dozen 
different  points  without  going  far  beyond  the  external  os.  To  render 
the  little  operation  antiseptic  and  aid  the  flow  of  blood,  a  continuous 
irrigation  of  warm  carbolic  solution  (1: 100)  is  kept  up.  This  is  very 
easy  to  do  with  the  little  funnel  which  I  have  adapted  to  the  spec- 
ulum (Fig.  72).     When  the  blood  has  flowed  long  enough,  the  spec- 


188  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

nlum  is  removed,  the  vagina  emptied,  and  a  tampon  of  iodoform 
ganze  placed  upon  the  cervix,  which  stops  the  bleeding. 

This  method  is  much  better  than  the  use  of  leeches,  does  not  re- 
quire anaesthesia,  being  painless,  and  may  be  repeated  as  often  (every 
other  day)  as  deemed  necessary. 

Exfoliative  metritis  or  membranous  dysmenorrhcea  is  both  ana- 
tomically and  clinically  an  acute  metritis,  or  better  the  acute  stage 
of  a  chronic  metritis.  Generally  every  other  treatment  than  curetting 
fails.  This  means,  on  the  other  hand,  gives  excellent  results.3  It 
should  be  followed  by  an  injection  of  tincture  of  iodine.  If  there 
is  at  the  same  time  stenosis  of  the  cervix,  both  that  and  the  pain 
are  treated  at  once  by  dilatation  with  laminaria  tents  or  Ellinger's 
dilator. 

Landowski  has  published 4  cases  successfully  treated  by  the  gal- 
vano-cautery;  the  method  is  a  good  one,  but  I  consider  the  curette 
more  expeditious. 

Acute  gonorrheal  metritis  should  be  energetically  treated  by 
antiseptic  and  slightly  caustic  vaginal  and  intra-uterine  •  injections. 
Alph.  Guerin  has  described  the  good  effects  of  an  intra-uterine 
injection  of  a  weak  solution  of  nitrate  of  silver  (gm.  0.05  to  gm.  30  of 
water).5  Fritsch 6  has  recently  recommended  the  use  of  chloride  of 
zinc,  1:100,  for  the  vagina;  more  concentrated  for  intra-uterine  cau- 
terization. Both  the  vaginitis  and  the  endometritis,  which  depend 
upon  each  other,  may  be  treated  together.  We  may  find  in  any 
case  that  the  inflammation  has  already  disappeared  from  the  vagina 
and  taken  refuge  in  the  uterine  cavity  or  the  urethra ;  it  is  in  this 
latter  place  that  we  seek  the  last  traces  by  which  to  characterize 
the  nature  of  the  uterine  affection.  For  the  vaginitis  and  the  urethri- 
tis injections  of  bichloride  have  always  given  excellent  results,  joined 
with  the  use  of  crayons  of  iodoform;  the  sublimate  should  be  of  the 
strength  of  1 :  2,000.  For  acute  gonorrhceal  metritis  I  employ  curet- 
ting followed  by  intra-uterine  cauterization  with  concentrated  chloride 
of  zinc  on  cotton  rolled  round  a  sound. 

Catarrhal  Metritis.— The  general  treatment  already  described 
should  be  most  carefully  followed ;  this  is  the  form  where  chloro-anse- 
mia  very  rapidly  appears  and  the  general  treatment  must  aid  the  local 
as  much  as  possible. 

This  is  also  the  form  where  it  is  most  necessary  to  maintain  entire 
cleanliness  and  rigorous  antisepsis  of  the  vagina ;  thus  one  acts  indi- 
rectly it  is  true,  but  very  efficaciously,  upon  the  cervix  which  is  often 


TREATMENT   OF   METRITIS.  189 

the  part  most  deeply  affected.  By  advising  the  patient  to  rest  in  bed 
after  the  morning  injection,  and  to  take  the  evening  one  in  bed  with- 
out rising  afterward,  a  certain  quantity  of  the  medicated  liquid  is 
kept  in  the  upper  part  of  the  canal,  making  a  kind  of  local  bath 
which  is  of  excellent  effect.  The  1 :  3,000  solution  of  sublimate  is  the 
best  for  injecting,  but  it  must  not  be  continued  for  too  long  a  time, 
because  of  the  danger  of  mercurial  poisoning.  Other  good  injections 
may  be  made  by  adding  to  a  pint  of  water  a  tablespoonful  of  pow- 
dered tannin,  or  two  of  boric  acid,  or  a  dessertspoonful  of  alum  in 
powder. 

To  cure  metritis  completely  it  is  necessary  to  attack  the  inte- 
rior of  the  organ.  The  three  principal  procedures  of  intra-uterine 
medication  are  :  antisepsis,  cauterization,  and  curetting,  employed 
together  or  singly.  To  these  it  is  often  necessary  to  add  surgical 
treatment  for  the  cervical  ulcers  and  lacerations  which  play  so  im- 
portant a  part  in  the  catarrhal  form  of  the  disease. 

I  will  follow  this  order  in  the  description  of  the  different  thera- 
peutic measures. 

Cleansing  of  the  Uterus. 

Intra-uterine  Irrigation. — Large  injections  of  some  feeble  an- 
tiseptic must  not  be  confounded  with  the  use  in  smaller  quantity  of 
agents  which  are  more  powerfully  caustic.  Schultze 7  has  especially 
praised  this  method.  He  dilates  the  cervix  with  laminaria,  introduces 
a  uterine  catheter,  and  washes  the  cavity  with  a  copious  injection  of 
weak  carbolic  solution  (1 :  50).  This  treatment  is  not  enough  in  obsti- 
nate cases,  and  I  think  it  should  be  reserved  for  those  light  attacks 
where  there  is  no  great  change  in  the  mucous  membrane,  for  there  it 
is  useful.  The  injection  may  be  given  every  day  through  a  two-way 
catheter;  if  there  is  any  difficulty  in  introducing  it,  the  cervix  should 
be  dilated  by  tent  or  instrument ;  a  half -litre  is  used  at  a  time.  When 
the  patient  does  not  soon  recover  after  the  employment  of  these  simple 
measures,  we  must  have  recourse  to  cauterization  and  the  curette. 

b.  Drainage. — Fehling  employs  glass  drains  pierced  with  holes; 
Ahlf eld,  hollow  cylinders  of  rubber;  and  Schwartz8  wicks  of  spun 
glass  which  act  by  capillarity.  It  does  not  seem  as  if  these  devices  had 
given  as  good  results  in  the  hands  of  others  as  their  authors  and  their 
pupils  have  obtained.  I  believe  that  the  presence  of  a  foreign 
body  in  the  uterus  would  be  more  likely  to  keep  up  the  metritis  than 


190 


CLERICAL   AND   OPERATIVE   GYNECOLOGY. 


to  cure  it.     It  is  otherwise  with  the  capillary  drainage  of  a  piece  of 
iodoform  gauze  described  in  the  next  paragraph. 

c.  Tampons.— Fritsch,9  since  1882,  has  employed  the  following 
measure  in  gonorrheal  metritis :  he  passes  into  the  uterus  a  strip  of 
iodoform  gauze  75  cm.  in  length  and  2  to  3  cm.  broad,  packing  it 

into  the  cavity  "  as  one  fills  a  hollow  tooth  " ; 
then  he  removes  it  and  repeats  the  manoeu- 
vre, thus  thoroughly  cleaning  the  uterus. 
After  this  he  introduces  another,  allows  it 
to  remain  twenty-four  to  forty-eight  hours, 
and  if  it  produces  colic  it  is  removed  by 
pulling  the  end  which  hangs  out  of  the 
vulva.  As  is  easily  seen,  this  procedure  has 
for  its  object  both  the  cleansing  and  the 
antisepsis  of  the  uterine  cavity.  But  it 
seems  to  me  much  less  simple  than  curet- 
ting followed  by  cauterization,  and  I  reserve 
the  uterine  tampon  for  energetic  disinfec- 
tion when  it  is  necessary  (as  in  cancer  of 
the  body,  sloughing  fibroma,  etc.),  or  I  em- 
ploy it  as  a  haemostatic  after  enucleation 
of  fibromata. 

d.  Sweeping  with  a  Tampon  and  Scrap- 
ing. —  Many  gynaecologists  content  them- 
selves with  dilating  the  cervix  and  cleansing 
the  uterine  cavity  by  means  of  a  pledget  of 
absorbent  cotton  rolled  on  a  handle.  This  is 
very  simple,  and  the  cotton  will  be  securely 
held  on  the  handle  if  the  end  of  it  is  a  little 
irregular;  Fritsch,  Tenneson,  Meniere,  Sims, 
and  Munde 10  have  invented  special  applica- 
tors ;  but  a  sound  with  no  terminal  enlarge- 
ment is  all  that  is  required  (Fig.  116).  It 
•is  easy  to  make  pledgets  of  tapering  form, 
so  that  they  can  be  passed  into  a  cervix  but  little  dilated.  It  is 
well  to  soak  these  in  a  1:1,000  solution  of  bichloride,  or  carbolic 
1 :  50,  to  gently  squeeze  the  excess  out  before  introducing  them,  and 
then  to  turn  them  about  within  the  uterine  cavity  so  that  the  walls 
of  the  organ  shall  be  thoroughly  wiped  clean.  The  last  tampon  may 
carry  the  caustic. 


Fig.  116.— Sims'  Slide  Applicator. 


TREATMENT   OF   METRITIS.  191 

Doleris  n  prefers  to  this  simple  means  the  employment  of  a  scraper 
like  that  used  in  cleaning  bottles  (Fig.  117);  the  instrument,  designed 
to  brush  the  interior  of  the  uterine  cavity,  is  rendered  aseptic  by  im- 
mersion in  1 :  100  sublimate  solution,  and  then  introduced  by  a 
spiral  motion,  which  is  kept  up  in  different  directions  until  it  is  re- 
moved. Both  the  scraper  and  the  tampon  may  be  charged  with  vari- 
ous medicating  solutions.  Doleris  thinks  that  by  using  scrapers 
with  harder  or  softer  bristles,  he  can  effect  both  a  cleansing  and  a 
scraping  of  the  mucous  membrane,  with  destruction  of  it  if  necessary. 
That  this  is  an  illusion  will  be  clear  to  all  those  who  are  accustomed 
to  use  the  blunt  curette,  and  know  the  amount  of  force  necessary 
to  remove  the  membrane  with  a  dull  instrument;  it  seems  to  me  im- 
possible by  simple  friction  of  the  mucous  membrane  with  a  brush 
to  destroy  its  elements. 

The  instrument  is,  therefore,  illusory,  and,  like  the  tampon,  cannot 
be  successful  as  a  means  of  either  cleansing  or  medicating  the  uterus. 

Fig.  117. — Dol£ris'  IScouyillon. 

From  this  double  point  of  view,  it  is  not  much  superior  to  the  tam- 
pon, which  I  employ  almost  wholly  for  the  cervical  cavity,  preferring 
to  clean  the  uterine  by  irrigation. 

There  are  cases,  especially  in  nulliparae,  where  the  cervix  is  full  of 
muco-pus,  but  the  external  os  is  narrow  and  prevents  the  escape  of  the 
secretion.  It  is  better  then,  instead  of  dilating,  which  would  require 
to  be  repeated,  to  make  a  small  crucial  incision  of  the  orifice;  this 
may  be  done  with  scissors  curved  on  the  flat  or  a  probe-pointed  bis- 
toury, and  the  cut  should  be  about  1  cm.  in  depth.  This  will  make 
applications  to  the  interior  of  the  cervix  easy,  as  well  as  complete  ex- 
amination of  the  part  and  the  decision  of  the  question  whether  a  more 
energetic  treatment  is  necessary:  the  small  incisions  heal  very 
quickly. 

Intra-uterine  Cauterization. — The  emjuoyment  of  solid  caustics 
— such  as  Becquerel  and  Rodier's  medicated  crayons,  Courty's  pen- 
cils of  nitrate  of  silver  left  in  the  uterine  cavity,  which  Spiegelberg 
removes  with  a  catheter  and  a  metallic  thread:  the  uterine  pistol  of 
E.  Martin  (senior),  imitated  by  Storer;  and  the  porte-caustic  of  Dittel 
— all  have  the  common  defect  that  they  blindly  leave  in  the  uterus 


192  CLIXICAL   A^fD   OPERATIVE   GYNAECOLOGY. 

a  caustic  with  an  action  either  too  strong  or  too  feeble.  The  direct 
momentary  application  of  the  agent  by  a  porte-caustic  is  preferable: 
but  beforehand  the  cavity  should  be  thoroughly  cleaned  by  irriga- 
tion or  tampons. 

Dumontpallier,  as  Polaillon  had  already  done,  introduces  into  the 
cavity  a  pencil  of  Canquoin  paste  (chloride  of  zinc).12  He^ produces 
thus  a  destruction  of  the  tissues  which  certainly  may  pass  beyond  the 
mucous  membrane  and,  T  think,  obliterate  the  orifice  of  the  Fallopian 
tube  and  cause  contraction  of  the  cervical  canal. 

Galvano-cautery  has  been  used  by  Spiegelberg 13  for  a  long  time, 
and  advised  anew  by  Apostoli.14  It  seems  both  less  easy  and  less 
sure  to  me;  for  it  may  cause  sterility  by  lining  the  interior  of  the 
uterus  with  cicatricial  tissue. 

Liquid  or  sirupy  caustics  are  easily  applied  with  a  thin  pledget 
of  cotton  wrapped  on  a  handle  or  special  sound.  The  method  has  been 
employed  by  many  authors  since  Miller15  and  Playfair  recom- 
mended it.  Pa  jot 16  uses  nitrate  of  silver  in  a  solution  of  equal  parts, 
or  in  powder  as  Richet  also  does,  or  as  a  paste,  also  acid  nitrate  of  mer- 
cury, anhydrous  nitric  acid,  chloride  of  zinc,  perchloride  of  iron, 
the  therm o-cautery  or  the  actual  cautery;  excepting  four  cases  of 
metro-peritonitis,  he  has  never  seen  a  serious  accident.  Pajot  does  not 
draw  the  uterus  down ;  he  carries  in  the  caustic  with  the  aid  of  a  long, 
flexible  whalebone  applicator  to  which  is  fastened  a  piece  of  cotton, 
very  much  as  Sims  employs  it. 

Rheinstadter 17  and  Broese  have  recently  advised  anew  the  use  of 
chloride  of  zinc,  dissolved  in  its  own  weight  of  water,  as  an  intra- 
uterine caustic,  applied  with  the  cotton-wrapped  applicator.  This 
method,  according  to  Broese,  never  produces  contraction  of  the  cervix, 
and  may  be  repeated  every  Aveek  or  twice  a  week,  without  confining 
the  patient  to  the  house.  The  uterus  does  not  need  to  be  held,  and 
the  caustic  is  rapidly  passed  in  through  a  cervix  dilated  enough  be- 
forehand to  prevent  any  difficulty  in  penetrating  into  the  cavity.  The 
contact  is  prolonged  only  one  minute,  and  any  drops  which  might 
attack  the  vagina  are  to  be  carefully  wiped  off.  [In  using  any  strong 
intra-uterine  caustic  it  is  advisable  to  protect  the  vagina  by  thin  tam- 
pons soaked  in  a  strong  solution  of  sodium  bicarbonate,  squeezed  dry 
and  packed  about  the  cervix.] 

Caustics  much  employed  in  America  are  weak  nitric  and  concen- 
trated carbolic  acids.  •  The  cervix  must  be  previously  dilated,  and 
certain  precautions  taken,  or  the  applicator  reaches  the  uterine  cavity 


TREATMENT    OF    METRITIS.  193 

after  most  of  the  caustic  lias  been  squeezed  out,  or  its  strong  action 
at  the  level  of  the  cervix  may  cause  subsequent  stenosis.  After  such  a 
cauterization  it  is  necessary  to  cleanse  the  uterine  cavity  with  great 
.  care. 

Peaslee  has  invented  a  speculum  designed  to  protect  the  cervix 
from  the  action  of  the  caustic,  but  it  is  not  convenient  in  use;  a 
simple  tube  of  glass,  such  as  Woodberry  of  Washington  em- 
ploys, would  be  better.  For  the  same  purpose,  Joseph  Hoffmann 
wraps  the  end  of  a  slender  syringe  tube,  pierced  with  many  holes, 
with  cotton  and  then  introducing  it  to  the  fundus,  forces  the 
fluid  out  by  the  gentle  play  of  the  piston,  thus  affecting  only 
the  mucosa  of  the  cavity. 

I  do  not  employ  these  methods.  In  spite  of  all  precautions,  it  is 
difficult,  whatever  may  be  said,  to  avoid  contraction  of  the  cervix 
after  cauterizing  the  entire  extent  of  its  orifice.  But  this  is  not  the 
principal  objection  which  could  be  made;  for  unless  each  cauterization 
is  preceded  by  a  dilatation,  or  the  intervals  are  employed  in  tampon- 
ing to  retain  the  dilatation,  one  cannot  be  sure  of  penetrating  well 
into  the  cavity  and  reaching  the  fundus.  Thus  there  is  a  part  of  the 
diseased  membrane  which  is  never  touched ;  while  the  cervical  portion 
is  too  strongly  cauterized,  the  action  is  nil  above.  The  first  cauteri- 
zations by  means  of  injections  were  made  a  long  time  ago  by  Lisfranc 
and  Vidal.18  Then  followed  much  discussion  as  to  the  possibility  of 
the  fluid  passing  into  the  Fallopian  tubes.  This  possibility  is 
easily  demonstrated  upon  the  cadaver,  under  conditions  not  found 
in  the  living,  but  practically  is  very  rare  if  two  things  are  provided 
for :  the  canula  must  not  fill  the  cervical  canal,  so  that  there  may  be 
plenty  of  room  left  about  it  for  the  fluid  to  pass  out  again ;  and  no 
great  force  must  be  used,  nor  should  the  jet  be  directed  in  the  axis 
of  the  uterus.  With  these  precautions  the  injection  may  be  made 
in  safety ;  both  are  realized  in  syringes  of  different  models,  particu- 
larly Braun's,  which  is  made  of  hard-rubber  and  may  be  used,  there- 
fore, with  any  fluid,  as  it  does  not  become  altered.  The  operation 
is  a  benign  one;  though  we  must  not  forget  certain  unfortunate 
cases,  in  some  of  whom  there  have  been  abnormal  anatomical 
conditions  (dilated  tubes),19  and  in  others  an  imperfect  operative 
technique. 

Many  fluids  are  used ;  the  best  being  tincture  of  iodine,  glycerin 
and  creosote,  and  perchloride  of  iron.  It  is  enough  to  inject  about 
three    grammes,    which    equals    the    contents    of    Braun's     syringe 

13 


194 


CLINICAL   AND   OPEEATIVE   GYNECOLOGY. 


(Fig.  118).  I  use  the  tincture  of  iodine  a  great  deal,  but  only  after  a' 
preliminary  curetting  several  days  before,  followed  by  injection  of 
perchloride  of  iron.  I  begin  the  iodine  injections  five  days  after  the 
operation,  and  in  very  intense  cases  of  catarrh  I  have  done  it  every 
second  day  through  two  weeks. 

I  prefer  the  tincture  of  iodine  in  a  solution  of  creo- 
sote (from  the  beech)  in  glycerin,  1 :  3  and  1 :  10,  as  Dole- 
ris  recommends.  The  canula  is  introduced  through  a 
speculum,  the  axis  of  the  uterus  having  been  ascertained 
beforehand.  If  there  is  any  difficulty,  the  cervix  should 
be  held  firm  with  a  bullet  forceps,  and  gentle  traction 
made  on  the  lip  opposite  to  the  flexion,  the  vaginal  walls 
being  kept  apart  by  the  valves  of  the  speculum.  As  the 
canula  is  slowly  withdrawn  from  the  fundus  toward  the 
cervix,  the  injection  is  performed  with  but  little  force. 
There  is  ordinarily  no  need  to  dilate  the  cervix,  unless 
the  canula  cannot  be  freely  moved  about  so  as  to  effect 
the  rapid  outflow  of  the  fluid.  During  the  intra-uterine 
injection,  the  vagina  is  to  be  copiously  irrigated  to  pre- 
vent cauterization  of  its  walls. 

I  have  seen  acute  pain,  vomiting,  and  fainting  follow 
such  an  injection,  but  never  any  serious  accident. 

The  objection  has  been  made  to  tincture  of  iodine, 
that  it  causes  precipitation  of  albumin,  and  the  forma- 
tion of  coagula  within  the  cavity  of  the  uterus.  This  is 
an  error  which  Nott's  experience  has  refuted.20  The 
iodine  simply  makes  a  layer  of  very  fine  precipitation 
upon  the  mucous  membrane,  and  its  antiseptic  action  is 
thus  prolonged  for  some  time.  The  essential  oils  and 
aromatics,  like  creosote,  etc.,  have  a  very  fugitive  action: 
and  iodoform  would  be  dangerous  from  the  effects  due 
to  its  absorption. 

Curettage.— I  adopt  this  word,  already  used  by  many 
authors,21  which  signifies  the  employment  of  the  curette, 
braun's  intra-  and  prefer  it  to  the  word  "  curage  "  (cleansing,  as  of  har- 
ttterinesyringe.  kors^  we]iSj etc)?  wMch  has  too  energetic  a  meaning,  or  to 
"  curettement "  the  German  name,  which  is  a  stupid  and  barbarous 
term,  like  many  others  in  German  which  have  been  borrowed  from 
French.  The  uterine  curette,  which  was  invented  by  Recamier  and 
fell  into  discredit,  has  again  come  into  favor  since  the  use  of  anti- 


TREATMENT   OF   METRITIS. 


195 


septics  in  gynaecology.     To-day,  in  France  as  well  as  in  other  coun- 
tries,22 it  occupies  an  important  place  in  the  treatment  of  metritis. 

The  choice  of  a  curette  is  not  a  matter  of  indifference.  There  are 
many  varieties,  of  which  the  principal  are — the  cutting  spoon  of  Simon 
(which  should  be  reserved  for  excision  of  cancer  of  the  cervix  and 
uterine  fungosities  very  far  advanced);   the  sharp  ring  curette  of 


Fig.  119. — Curettes,    a,  Simon's  sharp  curette;  b,  Thomas'  dull  curette  and  a  hooked  curette  for  removing 
debris  from  the  uterus;  c,  Sims'  sharp  curette;  d,  curette  of  Kecamier-Roux. 

Sims  (excellent  for  detaching  polypi);  the  flexible  dull  curette  of 
Thomas,  much  used  in  America;  and  the  dull  instrument  of  Recamier- 
Roux,  which  Martin  has  adopted  and  which  I  also  prefer.  It  presents 
the  advantage  over  the  ring  form,  that  it  removes  with  it  from  the 
cavity  the  greater  part  of  what  has  been  detached  (Fig.  119).  Curettes 
are  made  with  a  hollow  handle  and  a  perforated  top,  to  permit  irri- 
gation during  their  use.     I  do  not  find  that  this  simplifies  the  tech- 


196  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

nique,  and  they  are  hard  to  keep  clean.  I  am  a  resolute  partisan  of 
the  dull  (by  dull  I  mean  that  the  edges  are.  thin  but  not  cutting,  like 
a  knife-blade  which  has  not  been  hied)  curette  in  endometritis;  we 
have  not  here,  as  in  cancer,  to  remove  a  resistant  tissue ;  but  simply 
to  scrape  a  hard  muscular  wall,  covered  by  a  soft  investment  which  is 
still  further  softened  from  inflammation.  As  is  easily  understood,  it 
is  enough  to  scrape  the  interior  of  the  uterus  with  a  narrow  blade  to 
be  sure  of  detaching  all  that  is  not  strongly  adherent — and  that  is 
precisely  the  mucous  membrane.  Dull  curettes  have  the  further  ad- 
vantage that  with  them  there  is  the  least  risk  of  doing  injury  to  the 
parenchyma  of  the  organ,  for  if  the  force  used  is  never  too  great  and 
is  always  directed  obliquely,  it  is  impossible  to  perforate  the  wall  of 
the  uterus  (except  in  the  post-puerperal  state). 

By  the  curette  the  whole  thickness  of  the  membrane  is  never  re- 
moved ;  the  glands  penetrate  to  the  muscular  layer,  and  the  terminal 
culs-de-sac  remain  attached  to  the  parenchyma  in  spite  of  all  scraping, 
however  energetic,  and  serve  to  start  a  very  rapid  reconstruction  of 
the  membrane.23  It  is  this  fact  which  has  led  me  to  divide  curetting, 
both  in  my  course  and  in  the  thesis  of  Despreaux,  my  pupil,  into 
"  modifying  "  for  metritis,  "  destructive  "  for  malignant  neoplasm,  and 
"  exploratory  "  where  the  purpose  is  to  secure  a  small  piece  for  diag- 
nosis.24 In  the  two  latter  cases  the  cutting  instrument  is  to  be  pre- 
ferred. 

The  mucous  membrane  of  the  uterus  is  unique  in  its  special  power 
of  regeneration.  What  occurs  in  menstruation  and  pregnancy  dem- 
onstrates that  a  layer  equal  almost  to  its  whole  thickness  may  be 
expelled  and  rapidly  replaced.  The  curette  produces  artificially,  and 
for  a  therapeutic  object,  a  moulting  of  the  membrane  similar  to  that 
of  the  decidua;  it  substitutes,  so  to  speak,  in  an  antiseptic  way,  a 
regenerated  mucous  membrane  for  one  infected  by  germs  which  has 
already  suffered  such  changes  that  its  repair  would  be  very  long  and 
tedious.  After  curetting,  the  fecundity  of  the  woman  is  no  more  com- 
promised than  after  abortion  or  labor.  This  could  be  proved  a  priori, 
but  the  observations  of  Schroder,  Martin,  Duvelius,  Benicke,  Hein- 
ricius,  etc.,25  place  the  fact  beyond  all  doubt;  the  work  of  the  latter 
author  is  especially  demonstrative.  In  fifty-two  cases  where  he  was 
able  to  follow  the  patient,  sixteen,  or  30: 100,  became  pregnant;  in  two 
cases  five  weeks,  in  one  eight  weeks,  after  the  curetting.  One  may,  how- 
ever, exjject  the  next  menstruation  to  default,  and  sometimes  the  second 
or  the  third ;  I  have  in  one  case  seen  amenorrhcea  for  four  months. 


TREATMENT   OF   METRITIS.  197 

Technique  of  Curettage. — The  operation  should  be  done  by  prefer- 
ence in  the  first  days  after  menstruation.  Though  but  little  painful, 
I  prefer  to  anaesthetize  the  patient.  The  preliminary  antisepsis  of 
the  vagina  and  vulva  should  be  earned  out  according  to  the  rules  laid 
down  in  Chapter  I.  The  patient  is  placed  in  the  dorso-sacral  position, 
and  the  thighs  sivpported  by  two  assistants ;  the  one  upon  the  left  of 
the  operator  draws  down  the  short,  flat  valve  which  depresses  the 
fourchette,  the  other  holds  the  fixing  forceps  and  the  canula  for  con- 
tinuous irrigation.  The  patient's  knees  being  held  in  the  axilla,  each 
assistant  has  the  left  hand  free  and  can  at  need  hold  one  of  the  vaginal 
separators  (Fig.  11).  The  cervix  is  drawn  down  to  the  vulva  by  a 
Museux's  forceps,  with  teeth  opposite,  not  over-riding  (Fig.  120) 
which  is  fixed  in  the  anterior  lip.  The  uterine  sound  is  first  passed 
to  determine  anew  the  direction  and  depth  of  the  canal,  and  then  the 
curette  is  presented  at  the  external  os.  Nme  times  out  of  ten  it 
passes  without  difficulty ;  if  any  is  encountered,  the  cervix  is  at  once 


Fig.  120.—  Museux's  Forceps. 

opened  with  an  Ellinger's  dilator  or  by  passing  one  or  two  of  Hegar's 
bougies.  The  curette  is  then  directed  toward  the  fundus  of  the  uterus 
and  the  scraping  is  clone  by  bringing  it  first  over  the  anterior  face, 
then  the  posterior,  and  the  fundus,  the  angles  and -the  sides  in  turn. 
After  a  few  strokes  with  the  curette,  for  which  some  force  is  neces- 
sary, the  instrument  is  withdrawn,  and  at  once  plunged  into  a  vessel 
filled  with  strong  carbolic  solution  which  is  ready  at  the  right  of  the 
operator.  One  can  always  pass  twice  over  the  same  place,  and  make 
a  second  curetting,  supplementary  to  the  first,  following  the  same 
order  along  the  internal  surface  of  the  uterus.  The  operation  should 
be  done  rapidly ;  not  more  than  three  minutes  are  required.  Then  a 
double-current  catheter  of  Bozeman-Fritsch  is  introduced  (Fig.  8), 
and  the  surgeon,  seizing  the  canula  from  which  a  stream  has  not  ceased 
to  flow  gently  over  the  cervix,  fits  it  to  the  catheter  and  washes  the 
uterine  cavity  copiously  with  the  same  hot  carbolic  solution  which 
has  served  for  the  continuous  irrigation  (1 :  100).  A  quarter  or  a  half 
litre  should  be  injected,  until  the  water,  at  first  bloody,  returns  but 


198  CLINICAL   AND    OPERATIVE   GYNECOLOGY. 

little  tinted ;  the  effects  of  this  are  haemostatic,  antiseptic,  and  by  it 
the  clots  and  shreds  of  membrane  are  removed. 

The  catheter  is  taken  out,  and  replaced  by  a  Braun's  syringe  (full 
of  perchloride  of  iron  at  30°  C,  or  of  tincture  of  iodine),  which  is 
passed  up  to  the  fundus.  As  this  is  retracted,  its  contents  are  driven 
out  little  by  little,  scattering  them  through  the  cavity  from  fundus  to 
os  externum.  During  this  time,  continuous  irrigation  is  kept  up  with 
a  small  jet  against  the  cervix  to  wash  away  any  caustic  which  might 
escape  and  irritate  the  vagina  or  vulva. 

The  Bozeman-Fritsch  catheter  is  again  introduced  and  for  the 
second  time  the  cavity  of  the  uterus  is  thoroughly  washed  oat;  this 
removes  the  excess  of  the  caustic,  whose  action  should  be  rapid,  and 
also  the  last  remaining  clots.  If  there  is  any  difficulty  in  passing  the 
double-current  catheter,  one  can,  without  danger,  practise  the  injection 
in  small  intermittent  jets,  by  the  aid  of  the  long,  fine  canula  which 
has  served  for  the  continuous  irrigation,  taking  care  only  that  the 
uterus  is  not  distended  or  the  cervix  occluded  by  passing  the  canula 
too  deeply. 

When  the  operation  is  finished,  a  tampon  of  iodoform  gauze  is 
laid  over  the  os,  which  may  be  taken  out  on  the  second  day.  Every 
morning  and  evening  the  vagina  is  thoroughly  irrigated  with 
1 :  2,000  bichloride,  and,  if  the  catarrhal  metritis  has  been  very  stub- 
born, if  the  uterine  vegetations  have  been  very  plentiful,  or  if  there 
are  signs  of  salpingitis,  we  begin  to  make  intra-uterine  injections  of 
iodine  every  second  day;  four  to  eight  of  which  constitute  a  com- 
plete treatment. 

For  the  first  caustic  injection  which  immediately  follows  the  curet- 
ting, I  use  tincture  of  iodine  when  it  is  a  case  of  recent  catarrhal 
metritis ;  in  an  older  case,  or  where  the  oozing  demands  it,  I  employ 
perchloride  of  iron. 

Except  in  cases  of  pronounced  flexion  or  stenosis,  the  previous 
dilatation  may  be  omitted  in  women  who  have  had  children.  It  is 
not  needed  for  the  introduction  of  the  instrument,  it  is  illusory  as 
regards  the  escape  of  the  secretions,  for  artificial  dilatation  lasts  but 
a  few  hours,  and  as  to  the  debris  and  clots,  they  should  be  washed 
out  by  the  irrigation.  Now,  this  omission  is  not  of  trifling  importance 
the  first  time;  even  slight  dilatation  is  often  very  painful,  the  patient 
who  has  agreed  to  the  operation  has  probably  passed  a  sleepless 
night,  she  is  in  a  state  of  great  nervous  excitement,  and  to  this  may 
be  joined  some  fever  due  to  the  increase  in  the  inflammation  caused 


TREATMENT   OF  METRITIS.  199 

by  the  dilatation.  Therefore  I  have  given  up  dilatation  after  emrjloy- 
ing  it  three  years,  unless  there  is  special  indication  for  it ;  following 
in  this  respect  the  example  of  Martin,  Fritsch,  and  others.26  The  first 
of  these  observers  has  seen  it  cause  serious  trouble  in  a  case  of  intra- 
cervical  rjolypus  which  became  gangrenous  by  its  action. 

To  surgeons  not  familiar  with  the  curette,  perforation  of  the  uterus 
by  it  seems  a  horrible  possibility,  but  there  is  no  danger  of  it  if  we 
operate  with  a  dull  curette  and  always  obliquely  as  regards  the  uter- 
ine tissue,  after  clearly  determining  the  direction  of  the  organ.  It 
must,  however,  be  feared  after  labor  and  recent  abortion,  for  then  the 
uterine  wall  is  very  soft,  thin,  and  perforable  by  very  slight  force. 
The  patient's  own  statements,  the  size  of  the  uterus,  and  the  softness 
of  the  cervix  should  prevent  any  such  accident.  In  one  case  of  this 
kind  I  think  that  I  made  a  perforation,  because  of  the  great  depth  to 
which  my  curette  suddenly  passed  in  the  direction  of  the  umbilicus ; 
but  I  simply  did  not  give  the  intra-uterine  injection  and  the  patient 
recovered  with  no  other  accident  than  bilious  vomiting  the  day  after 
the  operation.  Doleris  has  thought  it  possible  to  exjilain  these  cases 
as  a  false  perforation,  the  illusion  being  produced  by  atony  of  the 
uterine  wall  which  allows  the  curette  to  depress  it  into  a  funnel 
shape;  this  seems  to  me  an  error.27  The  reported  observations  on 
this  point  prove  to  me  the  comparative  harmlessness  of  such  punc- 
tures under  antiseptics. 

As  a  possible  accident  with  curetting  one  may  mention  bleeding. 
In  many  hundred  cases  I  have  never  met  with  it ;  the  astringent  in- 
jection which  ends  the  operation  permits  nothing  more  than  an  insig- 
nificant oozing. 

Subacute  and  localized  peritonitis  need  only  be  mentioned ;  I  have 
never  seen  a  single  case:  exact  antisepsis  prevents  it  completely. 
Curetting  the  uterus  is  the  rational  treatment  for  catarrhal  metritis. 
If  simple  measures  have  failed,  general  treatment,  injections,  local 
applications,  etc.,  it  will  not  do  to  hesitate.  By  waiting  too  long,  time 
will  be  given  for  the  alteration  of  the  mucous  membrane  to  become 
more  advanced,  the  parenchyma  of  the  organ  is  exposed  to  sclerotic 
changes  and  follicular  degeneration,  esrjecially  in  the  cervix,  and, 
lastly,  we  must  not  forget  the  possible  extension  of  the  inflammation 
to  the  tubes,  so  frequent  in  old  cases  of  catarrhal  metritis. 

Mucous  polypi  may  be  removed  by  seizing  them  with  a  flat  forceps 
and  twisting  off  their  pedicle.  If  numerous  and  sessile,  the  cutting 
curette  of  Sims  or  Simon  should  be  used  and  the  bleeding  surface 


200 


CLINICAL   AND   OPEKATIVE   GYNAECOLOGY. 


touched  with  perchloride  of  iron  or  the  actual  cautery.  If  the  cervix 
is  very  much  altered,  if  there  is  follicular  hypertrophy,  we  have  re- 
course to  the  operation  of  Schroeder  described  below. 

Cervical  "  ulcerations  "  are  only  a  new  growth  of  glands,  more  or  less 
hypertrophied,  and  are  found  only  with  deep  inflammation  of  the 
mucous  membrane  of  the  body  of  the  uterus,  as  was  shown  a  long- 
time ago  by  Gosselin  in  the  reaction  from  the  narrow  doctrine  which 
dissociated  the  two.  Usually,  to  cure  the  ulcers  it  is  enough  to  cure* 
the  endometritis.  After  curetting  we  see  the  ulcers  disappear  as  does 
the  coating  from  the  tongue  after  vomiting,  but  this  is  true  only  of 
cases  taken  at  the  start.      Later  on,  the  glandular  proliferation  be- 


Fig.  121.— Uterine  Dressing  Forceps,  Straight  and  Elbowed,  for  Removal  of  Polypi. 

comes  a  settled  lesion  and  requires  for  its  cure  topical  modification 
or  removal  by  the  bistoury. 

As  the  first  treatment  of  the  ulceration,  we  must  employ  the 
curette ;  in  the  second  place  come  applications  of  nitrate  of  silver  or 
tincture  of  iodine,  practised  every  second  day.  In  America,  weak 
nitric  acid  (not  fuming)  has  been  much  used,  applied  with  a  very 
small  tampon  of  cotton  on  the  end  of  a  handle;  this  caustic  is 
preferred  to  chromic  acid  which  has  caused  intoxication;  but  all 
such  energetic  caustics  may  produce  contraction  of  the  cervix,  and  I 
avoid  them.  The  good  effects  of  chloride  of  zinc  have  also  been 
much  praised.  Rheinstadter  advises  the  hastening  of  the  action  of 
this  caustic  in  deep  ulceration  by  making  small  punctures  in  the  cer- 
vix. Hofmeier28  strongly  advocates  acetic  or  pyroligneous  acid.  He 
incloses  the  cervix  in  a  Fergusson's  cylindrical  speculum,  pours  in  a 
certain  quantity  of  the  acid,  and  lets  the  part  soak  for  a  few  min- 


TREATMENT   OF   METRITIS.  201 

utes,  the  gentle  action  of  the  caustic  attacking  almost  entirely  the 
cylindrical  epithelium  and  the  ulceration.  At  the  end  of  a  number 
of  these  seances  the  epithelium  has  become  pavement,  stratified,  and 
the  ulceration  is  healed.  The  trouble  may  persist  or  reappear  if  it 
penetrate  within  the  cervical  canal  and  the  os  be  narrow.  In  such  a 
case  it  is  advised  to  introduce  the  caustic  into  the  interior  of  the 
cervix  by  tampons,  which  I  consider  dangerous  from  the  stenosis  that 
may  result:  in  any  case,  only  the  weakest  caustics  should  be  em- 
ployed, and  they  but  for  a  short  time.  It  is  dangerous  to  attempt  the 
cure  of  an  old  ulceration  by  caustics;  for  thus  sclerosis  of  the  cervix 
is  produced,  and  cysts  by  the  obliteration  of  the  glandular  orifices. 
But  when  the  ulcer  is  recent,  cervical  cauterization  following  the  use 
of  the  curette  for  the  endometritis  is  excellent  therapy,  capable  of 
giving  rapid  and  lasting  success.  This  distinction  is  important.  It 
has  not  been  made  by  Doleris  and  Mangin,29  who  condemn  every  at- 
tempt at  "  epidermization,"  even  for  the  purpose  of  hastening  the  cure 
of  a  recent  lesion. 

When  other  means  fail,  or  when  the  patient  will  not  follow  a  treat- 
ment which  demands  months,  asking  to  be  rapidly  cured,  even  by 
operation,  then  the  surgical  treatment  is  of  great  service.  Excision 
of  the  affected  mucous  membrane  by  Schroder's  oj)eration  has  given 
excellent  results;  it  substitutes  a  healthy  for  a  diseased  membrane 
and  permits  the  removal  of  parts  which  have  undergone  cystic  degen- 
eration. It  makes  no  large  scar  and  hence  is  no  obstacle  to  labor,  as 
many  observations  prove.  My  practice  is  to  do  it  after  curetting,  in 
the  same  session.  The  operation  is  especially  indicated  in  the  follow- 
ing conditions:  in  old  ulcers  of  the  cervix,  with  hypertrophy;  in 
ulceration  with  stenosis  of  the  canal;  in  ulceration  with  deep  lacera- 
tion. It  is  far  superior  to  Emmet's  operation,  all  of  whose  indications 
it  fulfils. 

Erosion  Complicated  by  Laceration. — We  know  the  capital  role 
which  this  condition  plays  in  uterine  pathology  according  to  Emmet. 
His  enthusiasm  has  had  the  good'  effect  of  showing  that  the  element 
of  laceration,  before  neglected,  is  not,  however,  to  be  disregarded.  Is  it 
the  previous  inflammation  of  the  cervix  which  prevents  the  laceration 
from  healing,  as  Scaiqder  thinks,  or  is  it  the  laceration  which  pro- 
vokes the  catarrh  and  maintains  the  ulceration,  as  Emmet  believes  ? 
I  am  inclined  to  fear  that  we  have  here  one  of  those  vicious  circles 
that  are  so  frequent  in  general  pathology.  At  any  rate,  Emmet's  oper- 
ation, to  which  Dudley,  of  Philadelphia,  has  given  the  name  of  "  tra- 


202  CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 

chelorrhaphy,"  cannot  be  performed  on  an  ulcerated  cervix  nntil  it  is 
healed,  or  else  we  shut  the  wolf  up  in  the  sheepfold.  Emmet  lays 
down  a  preparatory  treatment  which  lasts  months ;  there  is  hence  no 
comparison  between  his  and  Schroder's  operation:  the  latter  is  de 
signed  especially  for  cervical  catarrh,  the  former  for  nodular  tissue  due 
to  laceration.  For  Emmet  the  ulceration  is  only  accessory,  the  main 
lesion  being  the  sclerosis  which  compresses  vessels,  nerves,  and  glands. 
For  this  reason  I  will  describe  trachelorrhaphy  in  the  section  on 
chronic  metritis,  since  it  is  not  a  question  so  much  of  the  ulcers  seen 
in  catarrhal  metritis  as  of  the  cicatrices  met  with  in  the  chronic  form 
of  the  disease. 

Lacerations,  then,  with  extensive  ulceration,  demand  excision  of 
the  mucous  membrane,  or  Schroeder's  operation,  which  procures  the 
prompt  healing  of  the  ulcerations  and  at  the  same  time  restores  the 
external  os  better  than  trachelorrhaphy. 

When  the  surface  involved  is  not  large,  it  may  be  caused  to 
cicatrize  by  the  application  of  the  actual  cautery  or  simple  caustic; 
but  this  means,  good  enough  in  mild  cases,  should  not  be  used  where 
the  ulceration  is  extensive.  The  granulation  tissue  so  produced  is  in 
itself  a  pathological  element — a  fact  which  does  not  seem  to  have 
been  grasped  by  those  gynaecologists  who  use  and  abuse  the  hot  iron. 

Hemorrhagic  Metritis. — The  treatment  may  be  divided  into  two 
parts — for  the  bleeding,  which  is  palliative  but  must  be  at  once  carried 
out;  and  for  the  disease  itself,  which  should  be  curative. 

Palliative  Treatment  for  the  Hemorrhage. — The  patient  is  kept 
in  the  horizontal  position,  and  prolonged  vaginal  injections  of  very  hot 
water  should  at  first  be  tried;  ergot  is  of  very  little  use.  Gallard30 
has  strongly  advocated  digitalis,  which  he  says  influences  the  symp- 
tom and  the  inflammatory  state  at  the  same  time.  He  advises  the 
infusion  of  the  leaves  (0.03-0.05  in  125  gm.  of  water),  of  which  the 
woman  drinks  during  the  day  by  the  tablespoonful.  A  remedy 
which  I  have  tried  with  good  results  is  fluid  extract  of  hydrastis  cana- 
densis, in  twenty-drop  doses  thrice  a  day;  the  medicine  is  also  an 
excellent  stomachic.31 

Dilatation  of  the  cervix  or  the  introduction  of  a  tent  of  laminaria 
will  sometimes  stop  the  bleeding  temporarily,  but  the  respite  ob- 
tained is  short.  The  action  is  due,  no  doubt,  to  contraction  of  the 
uterine  body  and  to  vaso-motor  reflex. 

As  to  injection  of  perchloride  of  iron,  the  amelioration  is  only 
temporary,  whatever  may  have  been  published  of  cures  from  its  use; 


TREATMENT   OF   METRITIS.  203 

the  patients  were  not  followed  long  enough  to  prove  any  such  asser- 
tions. 

In  case  of  persistent  bleeding  we  may  try  vaginal  tampons ;  they 
can  be  made  with  alum  cotton  (p.  80)  or  large  pieces  of  gauze ;  ordi- 
nary iodoform  gauze  is  too  permeable,  and  Lister's  carbolic  gauze 
should  be  employed,  made  with  resin;  it  is  also  well  to  powder  it 
with  iodoform.  I  will  next  describe  a  palliative  measure  which  has 
given  good  results  under  Fritsch,  and  which  I  have  seen  Martin  em- 
ploy, viz.,  ligature  of  the  uterine  arteries.32  It  is  done  without  inci- 
sion into  the  vagina,  by  tying  in  mass  across  the  cnl-de-sac  (see  p.  117). 
Fritsch  recommends,  for  greater  surety,  to  make  an  incision  on  each 
side  of  the  cervix,  about  3  cm.  long ;  the  first  branches  met  are  two 
vaginal  twigs,  then  more  deeply  the  trunk  of  the  uterine;  both  are 
tied.     I  do  not  hesitate  to  proceed  thus  in  an  urgent  case. 

The  best  haemostatic,  and  at  the  same  time  the  curative  treatment, 
is  curetting.  It  should  be  practised  as  soon  as  possible,  according  to 
the  rules  already  given,  and  be  followed  by  an  injection  of  perchloride 
of  iron  at  30°  C.  The  operatiou  may  be  done  while  the  bleeding  is 
free;  I  have  often  seen  it  at  once  arrested  after  the  curettage,  which  I 
attribute  not  only  to  the  destruction  of  the  bleeding  tissue,  but  also 
to  the  contraction  of  the  muscular  fibres  in  the  vessel  wall  provoked 
by  the  scraping.  A  single  injection  is  usually  sufficient;  the  cure  is 
rapidly  obtained. 

There  are  certain  rare  forms  called  by  the  name  of  hemorrhagic 
metritis,  where  all  means  fail  and  the  bleeding  persists,  threatening 
the  life  of  the  patient.  In  such  a  case  the  last  resort  is  either  castra- 
tion, to  produce  an  artificial  menopause,  or  vaginal  hysterectomy,33  to 
remove  the  very  source  of  the  hemorrhage.  The  exciting  cause  may 
be  an  unrecognized  alteration  of  the  adnexa  with  a  symptomatic 
pseudo-metritis.  At  any  rate,  this  is  our  only  refuge  where  all 
other  means  remain  powerless  and  it  is  a  question  of  the  life  of  the 
patient. 

Chronic  Painful  Met? it  is. —Local  bleedings  by  scarification  of  the 
cervix  find  here  a  frequent  application;  not  only  is  the  immediate 
antiphlogistic  effect  desired,  but  also  the  evacuation  of  the  cysts, 
superficial  and  deep,  which  are  scattered  over  the  surface  of  the  neck 
of  the  uterus.  As  regards  cauterization  with  the  hot  iron  and 
thermo-cantery,  and  especially  ignipunctnre,  so  praised  by  certain 
authors,  and  whose  usefulness  I  doubt,  I  consider  them  all  inferior  to 
puncture  and  scarification  with  the  bistoury;  the  scars  which  follow 


204  CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 

their  use  tend  to  favor  cystic  degeneration,  by  adding  to  the  sclerosis, 
and  also  to  cause  contraction  of  the  canal,  and  compression  of  the 
nerves,  with  the  accompanying  morbid  reflexes. 

It  is  very  advisable  to  employ  antiphlogistic  dressings,  consisting 
of  a  coat  of  tincture  of  iodine,  to  the  cervix,  followed  by  a  glycerin 
tampon  to  which  is  added  a  very  little  iodoform.  Some  authors  use 
a  glycerin  solution  of  iodide  of  potash  (5 :  100),  but  I  see  no  real  ad- 
vantage in  this. 

The  application  of  a  simple  glycerin  tampon  must  not  be  con- 
founded with  complete  tamponing  of  the  vagina,  or  its  "  columniza- 
tion,"  as  the  Americans  say  (page  80).  I  refer  to  the  method 
recommended  by  Bozeman,  and  extolled  afterward  by  Taliaferro,34 
whicji  is  in  general  use;  with  many  of  the  American  gynaecologists 
it  is  the  sovereign  remedy  for  chronic  metritis  and  the  exudations 
of  perimetritis.  The  column  of  cotton  (ordinary)  which  fills  the 
vagina  is  for  the  viscera  what  an  elastic  bandage  is  to  a  relaxed  part 
(Engelmann33).  It  gives  a  support  to  the  uterus  and  ovaries,  removes 
traction  from  the  ligaments,  and  provokes  the  absorption  of  plastic 
products. 

Pallen,  thinking  that  the  cotton  was  insufficient,  did  not  hesitate 
to  till  the  vagina  with  clay.  Reeves  Jackson  rejected  the  cotton, 
which  was  apt  to  settle,  and  employed  wool  from  which  the  grease 
had  been  removed,  as  being  more  elastic.  I  am  content,  unless  there 
is  a  uterine  deviation,  to  place  a  series  of  small  pieces  of  glycerinated 
cotton  carefully  about  the  cervix  in  the  cul-de-sac,  packing  them 
lightly  so  that  they  form  a  ring  like  a  pessary.  The  best  position  in 
which  to  put  the  patient  is  the  genu-pectoral,  which  permits  the  ascent 
of  the  viscera  and  assures  their  final  support.  The  tampons  may  be 
left  in  place  four  or  five  days,  if  to  the  glycerin  a  little  iodoform  has 
been  added.  The  latter,  it  is  true,  may  give  rise  to  accidents  36  if  too 
long  used;  with  the  first  signs  of  its  absorption,  such  as  malaise, 
headache,  loss  of  appetite,  and  alteration  of  the  urine,  it  should  be 
discontinued.  But  these  evil  effects  are  never  observed  if  it  is  used 
at  intervals,  with  precautions  against  constipation,  which  seems  to 
me  to  play  an  indisputable  role  in  predisposing  to  its  absorption. 

Hot  injections  are  often  of  great  aid,  in  two  conditions;  in  a 
chronic  metritis  where  there  is  a  complicating  perimetritis,  more 
or  less  pronounced ;  and  with  very  sensitive  patients  who  complain  of 
acute  pain,  as  in  the  case  of  what  Lisfranc  calls  hysteralgia,  chronic 
metritis  without  hypertrophy,  and  which  Routh  has  termed  the  irri- 


TREATMENT    OF    METRITIS.  205 

table  uterus.     In  such  cases  I  have  had  excellent  results,  and  cannot  ■ 
too  strongly  recommend  this  special  hot  irrigation.37 

Good  effects  have  been  obtained  with  electricity;  for  this  a  bi- 
polar exciter  is  introduced  into  the  uterus.38 

Massage  has  been  much  recommended  in  chronic  metritis,  as  well 
as  for  prolapse,  displacement,  and  chronic  perimetritis.  There  is  a 
clear  distinction  to  be  made  between  general  massage,  a  kind  of 
passive  gymnastics,  which  favors  nutrition  and  can  only  be  useful  if 
practised  with  method;  and  local  massage,  which  claims  to  dimin 
ish  congestion  and  volume  by  manipulation  of  the  diseased  organ. 
This  latter  form  consists  in  passing  two  fingers  into  vagina  or  rectum, 
supporting  the  posterior  face  of  the  uterus,  and  with  the  other  hand 
above  the  pubis  making  gentle  progressive  pressure,  like  a  kind  of 
kneading.  In  spite  of  the  favor  which  this  method  enjoys  in  Sweden,39 
in  spite  of  the  good  results  published  by  Reeves  Jackson,  Runge, 
Prochownik,40  etc.,  I  have  hesitated  to  employ  this  two-edged  tool, 
which  might  so  easily  cause  some  accident  to  the  uterus  or  its  adnexa. 
I  will  not,  however,  condemn  a  therapeutic  measure  which  is  espoused 
by  serious  gynaecologists,  and  which  I  have  not  employed;  I  merely 
reserve  my  decision. 

There  remain  certain  cases  of  chronic  painful  metritis,  a  great 
number  of  them,  for  which  all  measures  are  powerless;  the  cervix 
continues  to  be  large,  swollen,  hard,  and  mammillated  in  spite  of  all 
scarification,  topical  applications,  and  thermal  cures;  the  body  is  in- 
creased in  size,  heavy  and  painful  on  ballottement ;  the  patients  are  so 
weak  that  the  least  walking  tires  them,  all  exercise  is  troublesome. 
It  is  in  these  cases  that  surgery  renders  great  service  by  means  of  an 
operation  which  acts  upon  the  cervix  and  reacts  upon  the  uterine 
body;  namely,  amputation. 

Amputation  of  the  cervix  in  metritis  has  already  a  long  history; 
Lisfranc  used  it  and  abused  it ; 41  then  the  operation  fell  completely 
into  disfavor.  To  Carl  Braun,42  of  Vienna,  is  due  the  credit  of  re- 
introducing it  and  establishing  it  upon  a  sound  basis.  Braun's  great 
work  described  the  alteration,  the  involution,  which  the  body  of  the 
uterus  undergoes  after  operation  upon  the  cervix ;  following  such  an 
operation  for  hypertrophy,  Braun  saw  a  great  diminution  in  the  size 
of  the  uterine  body.  The  autopsy  of  one  of  these  old  operation  cases 
demonstrated  that  this  decrease  was  due  to  a  fatty  degeneration  of 
the  connective  tissue — an  opinion,  however,  which  is  not  well  founded. 
It  is  very  possibly  due  to  the  lessened  congestion  from  the  loss  of 


206  CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 

blood  and  to  the  rest  in  bed,  but  far  more  to  an  actual  vaso-motor  and 
trophic  reflex,  caused  by  the  cervical  traumatism.  Whatever  may  be 
the  explanation,  the  fact  is  undeniable  that  the  volume  of  the  uterus 
diminishes  after  every  operation  upon  its  neck,  as  I  have  often  ob- 
served after  the  operations  of  Simon,  Schroeder,  and  Emmet.  Braun's 
work  roused  no  enthusiasm  until  August  Martin 43  demonstrated  the 
important  place  in  therapeutics  which  the  procedure  holds,  and 
adopted  a  technique  far  superior  to  the  action  of  the  ecraseur  or  the 
galvano-cautery  employed  by  his  predecessors. 

It  might  be  said  that  amputation  of  the  cervix  is  always  to  be  held 
as  our  last  resort  in  all  cases  of  chronic  metritis  with  hyperplasia. 
Moreover,  in  cases  of  sclerosis  of  the  cervix  it  restores  the  calibre  and 
suppleness  of  the  external  orifice  and  stops  the  dysmenorrhoea  caused 
by  its  rigidity  and  irregularity. 

A  complete  contra-indication  to  the  operation  would  be  coexisting 
acute  perimetritis ;  but  I  do  not  hold  the  same  opinion  where  the  in- 
flammation is  old,  with  sequelae  like  adhesions,  etc.  There  is  always 
a  fear  that  the  ancient  focus  will  become  active  after  even  a  perfectly 
antiseptic  operation  upon  the  uterus,  whether  it  be  amputation  of 
the  cervix,  curettage,  or  simply  infra-traction.  We  must  then,  if  we 
do  not  altogether  refrain  from  surgical  interference  in  such  cases,  be 
on  our  guard,  and  search  out  beforehand  any  focus  in  the  adnexa  or 
adhesions  which  may  be  present  whence  accidents  may  result. 

The  operative  technique  has  been  perfected  and  at  the  same  time 
simplified  by  the  use  of  a  cutting  instrument.  The  fear  of  hemor- 
rhage was  natural  at  a  time  when  the  operation  was  done  laboriously 
at  the  bottom  of  the  vagina.  Moreover,  the  fashion  was  to  employ 
various  haemostatic  measures,  like  extemporaneous  ligature,  the 
linear  ecraseur,  galvano-  and  thermo-cautery.  Previous  compression 
with  a  ring  of  rubber,  which  many  operators  advise,  shows  the  same 
exaggerated  prudence.  When  the  operation  is  rapid,  there  is  but  lit- 
tle bleeding,  which  the  sutures  arrest  at  once  and  completely;  we 
need,  however,  to  tie  them  tightly  and  securely. 

Every  amputation  by  the  ecraseur  or  the  galvano-cautery  has  the 
fatal  disadvantage  of  leaving  a  harsh  cicatrix,  with  concentric  con- 
traction, ending  in  stenosis.  Other  circular  amrmtations  with  bis- 
toury or  guillotine  have  the  same  defect,  though  to  a  less  degree,  and 
the  bleeding  is  hard  to  stop. 

The  only  amputations  which  are  to  be  commended  are  those  which 
allow  perfect  coaptation  and  suture  of  the   divided  mucous  mem- 


TREATMENT   OF   METRITIS. 


207 


brane,  with  the  formation  of  an  orifice  not  liable  to  contract.  Two 
procedures  of  this  kind  may  be  adopted  according  to  special  indi- 
cations (1)  amputation  with  two  naps  for  each  lip,  or  (2)  with  but 
one  which  may  be  so  graduated  as  to  become  only  an  excision  of  the 
internal  mucous  membrane. 

Amputation  of  the  Cervix  with  Double  Flaps — Conical  Exci- 
sion.— This  procedure,  suggested  by  Simon,  generally  bears  the  name 
of  Marckwald,44  who  was  the  first  to  describe  it  methodically.     It  is 

to  be  preferred  when  the  internal  mem- 
brane of  the  part  is  not  affected  and  does 
not  need  to  be  removed. 

The  following  is  a  short  description  of 
the  technique :  Anaesthesia ;  lithotomy  po- 
sition; fourchette  depressed  by  an  assis- 
tant with  a  short  speculum;  continuous 
irrigation  made  with  small  stream  by  the 
assistant  who  holds  the  fixing  forceps, 
either  with  Fritsch's  irrigation  speculum 
or  a  long  canula.  Division  of  the  cervical 
commissures  with  a  convex  bistoury  of 


Fig.  122.—  Amputation  of  the  Cervix  with  Double  Flaps  (Simon).    A,  Sectional  view  showing  lines 
of  incision  for  formation  of  flaps  and  method  of  suture;  B,  front  view  of  cervix,  operation  complete. 


large  size  or  strong  scissors.  The  incision  of  the  anterior  lip 
goes  deeply  through  the  internal  surface,  obliquely  from  below  up- 
ward; the  second,  through  the  anterior  mucous  membrane,  joins 
the  other  so  as  to  form  a  conical  segment  of  the  anterior  lip,  its 
base  below,  its  apex  above.  Suture  of  the  two  lips  thus  formed 
with  a  sharp  needle,  threaded  with  catgut,  taking  care  to  pass  it 
under  the  whole  bleeding  surface ;  five  or  six  points  are  necessary. 
The  same  manoeuvre  on  the  posterior  cervical  lip,  after  removal  of  the 
fixing  forceps,  using  the  first  sutures  to  depress  the  organ.     Suture 


208 


CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 


of  the  commissures  by  one  or  two  points.  Cutting  of  the  threads, 
vaginal  irrigation,  uterus  restored  to  its  place,  iodoform  tampon  (Fig. 
122,  A,  B), 

At  the  end  of  three  days  the  tampon  may  be  withdrawn,  and  anti- 
septic irrigation  practised  morning  and  evening  (1 :  2,000  bichloride). 
It  is  necessaray  to  keep  the  patient  in  bed  during  at  least  five  days ; 
union  is  then  complete;  there  is  no  need  of  removing  the  sutures, 
which  fall  of  themselves. 

This  operation  is  easier  of  execution  than  Hegar's,  which  differs  in 
the  absence  of  the  first  step,  the  incision  of  the  commissures ;  as  to 
the  method  of  Sims,  where  the  vaginal  mucous  membrane  alone  is 
sutured  above  the  wound,  that  was  considered  an  improvement 
when  it  appeared,  but  it  is  now  superseded. 

Amputation  of  the  Cervix  with  Single  Flap.  Excision  of  the 
Mucous  Membrane.    Schroedefs  Operation. — This  is  especially  ap- 


Fig.  133. — Amputation  of  the  Cervix  by  one  Flap  or  Excision  of  the  Mucosa  (Schroeder's  Opera- 
tion). A,  Showing  method  of  placing  the  sutures;  1  and  2  are  those  uniting  the  commissures;  B,  section 
showing  shape  of  incisions  and  (b  c)  line  of  suture;  C,  shows  position  of  lips  after  suturing. 


plicable  to  the  catarrhal  form,  where  there  is  rebellious  ulceration  and 
follicular  degeneration  more  or  less  deep ;  but  it  may  be  adopted  in 
any  chronic  metritis  where  from  the  shape  or  consistence  of  the  cervix 
it  is  more  convenient. 

This  operation  of  Schroder's 45  is  coming  rapidly  into  favor  else- 
where, and  is  beginning  to  be  adopted  in  France,  where  I  was  one  of 
the  first  to  practise  it.46 


TREATMENT   OF   METRITIS.  209 

Its  execution  is  a  little  more  difficult  than  the  preceding.  The 
cervix  is  made  accessible  and  the  bilateral  incision  made  as  above; 
from  that  we  proceed  as  follows:  Transverse  incision  of  the  inter- 
nal mucosa  and  semicircular  incision  of  the  external,  forming  thus  a 
layer  of  tissue  which  is  dissected  from  without  till  the  internal 
transverse  incision  is  reached  and  the  layer  is  wholly  detached;  the 
thickness  of  this  varies  according  to  the  alteration  of  the  tissue.  In- 
folding, entropion,  of  the  lip  thus  formed  and  suture  internally  by 
five  or  six  j)oints  with  catgut,  the  needle  being  passed  below  the 
whole  bleeding  surface;  two  or  three  auxiliary  sutures  superficially 
placed.  The  same  dissection  and  suture  of  the  posterior  lip,  the  cer- 
vix being  held  firm  by  the  threads  already  passed.  Suture  of  the 
commissures,  etc.,  as  above  (Fig.  123). 

At  times  there  may  be  an  advantage  in  making  the  twofold  inci- 
sion on  one  of  the  cervical  lips  and  the  single  one  on  the  other.  It  is 
well  also  to  precede  the  operation  by  a  curetting  of  the  body  where 
the  mucous  membrane  is  always  somewhat  altered.  I  prefer  to  do 
this  after  the  amputation,  so  as  not  to  be  disturbed  by  the  bleeding, 
and  to  operate  on  the  part  while  it  is  not  shrivelled  by  the  per- 
chloride. 

Emmet's  Operation}'1  Trachelorrhaphy. — As  I  have  said,  this 
should  yield  to  Schroder's  operation  whenever  with  cervical  lacera- 
tion there  is  also  cervical  catarrh.  Emmet's  operation,  then,  should  be 
saved  for  chronic  metritis  without  erosion  of  the  cervix.  One  might 
then  hope,  by  removing  cicatricial  tissue  and  restoring  the  normal 
shape  of  the  part,  to  cause  the  disappearance  of  the  pains  and  irrita- 
tion ;  all  the  more,  because  the  trauma  of  the  cervix  usually  promotes 
involution  of  the  body  of  the  uterus,  an  important  factor  in  the  suc- 
cess obtained.48 

The  patient  is  anaesthetized  and  the  assistants  are  disposed  as  be- 
fore; the  cervix  is  seized  with  forceps  (in  America  a  thread  passed 
through  each  lip  is  preferred) ;  one  forceps  catches  the  anterior  lip 
close  to  the  laceration,  the  other  is  placed  opposite,  symmetrically; 
then. the  borders  of  the  laceration  are  dissected  out  in  a  single  piece, 
being  careful  to  reach  the  depth  of  the  angle  and  to  remove  all  the 
cicatricial  tissue  (Emmet).  The  wound  is  then  equalized,  if  neces- 
sary, by  curved  scissors.  The  first  suture  is  then  passed  with  a 
strong  curved  needle  near  the  angle  of  the  wound,  piercing  the  thick- 
ness of  both  sides  two  mm.  from  the  external  surface  and  one  mm.  from 
the  internal,  and  each  suture  is  tied  at  once  to  secure  perfect  coapta- 

14 


210  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

tion  of  the  parts.  Four  to  eight  sutures  are  thus  passed.  I  use  cat- 
gut, which  has  the  advantage  of  falling  out  by  itself ;  two  sizes  should 
be  employed,  the  smaller  for  any  superficial  sutures  which  may  be 
necessary. 

Lately,  under  the  influence  of  Lawson  Tait,  there  has  been  a  reac- 
tion against  any  loss  of  substance  in  plastic  operations.  Applying 
the  principle  of  the  flap -splitting  operations  to  trachelorrhaphy, 
Sanger49  and  Fritsch  advise  the  following:  Excision  of  the  superior 
angle,  then  partial  splitting  of  the  lips  of  the  laceration  by  an  incision 


Fig.  124. — Emmet's  Operation.     [This  cut  shows  the  common  fault  of  insufficient  denudation.] 

from  above  downward,  and  suture  at  the  external  surface  alone.  An 
iodoform  tampon  left  in  place  three  days  is  all  the  dressing  needed. 
After  this,  antiseptic  vaginal  irrigation  morning  and  evening,  and  rest 
in  bed  for  two  weeks. 

When  the  laceration  is  bilateral  it  is  almost  impossible,  in  doing  a 
trachelorrhaphy  on  both  sides,  to  avoid  narrowing  the  cervical  canal 
I  therefore  prefer  Schroder's  operation,  which  is  in  these  conditions 
more  expeditious  and  permits  thorough  removal  of  the  sclerosed 
tissue. 

After  any  procedure  of  this  kind  it  is  well  to  explore  the  cavity  of 
the  uterus  with  a  curette,  and,  if  anything  soft  and  friable  is  found, 
to  do  a  complementary  curettage,  which  does  not  complicate  the 
principal  operation. 

There  are  few  operations  which  have  had  such  passionate  par- 
tisans and  detractors  as  trachelorrhaphy.     While  certain  authors  have 


TREATMENT   OF   METRITIS. 


211 


accused  it  of  producing  sterility  and  of  complicating  labor,50  others 
have  extolled  it  as  a  remedy  against  this  very  sterility,51  while  some 
have  not  hesitated  to  do  it  on  pregnant  women,  demonstrating  at 
least  by  their  boldness  the  harmless  nature  of  the  procedure.52 

To  me  it  seems  certain  that  the  operation,  well  done,  need  have  no 
bad  results,  though  it  has  no  advantages ;  it  is  probably  often  done 
unnecessarily. 

[I  cannot  agree  with  the  author  in  his  statements  concerning  Em- 
met's operation  which,  while  in  most  instances  it  removes  hyperplastic 

tissue  as  effectually  as  the  meth- 
ods favored,  has  the  manifest  ad- 
vantage of  restoring  the  cervix  to 
its  natural  ante-partum  condition 
instead  of  mutilating  it  by  what 
is  practically  an  amputation. 
Each  method  has  its  own  indica- 
tions, and  trachelorrhaphy  is  to 
be  reserved  for  cases  with  deep 
cervical  tears  with  more  or  less 


[Fig.  135.— Diagram  Showing  Area  of  Denudation 
and  Arrangement  of  Sutures  in  Emmet's  Operation 
(Trachelorrhaphy).] 


[Fig.  126. — Appearance  of  Cervix  after 
Sutures  are  Tied.] 


glandular  or  parenchymatous  hyperplasia  and  endometritis,  or  with 
symptoms  dependent  on  nervous  reflexes.  If  the  degree  of  thicken- 
ing and  hyperplasia  is  not  marked,  as  in  somewhat  recent  cases,  the 
typical  operation  as  shown  in  Fig.  125  will  be  sufficient;  care  being 
taken  to  denude  thoroughly,  removing  all  the  diseased  tissue,  and  to 
unite  the  surfaces  accurately;  denudation  and  union  of  the  edges 
only,  as  shown  in  the  author's  diagram  (Fig.  124),  being  crefully 
avoided. 

In  cases  with  great  hyperplasia  more  tissue  must  be  removed,  so 
that  the  operation  then  resembles  in  its  first  ster>s  that  of  Schroder, 


212  CLINICAL   AND   OPERATIVE  .GYNAECOLOGY. 

and  becomes  practically  a  flap  amputation.  The  sutures  may  be  in- 
serted in  the  same  manner  as  at  first,  with  the  addition  of  a  plug  of 
glass,  hard  rubber,  or  drainage  tube  long  enough  to  reach  to  the  in- 
ternal os,  which  is  laid  in  the  line  of  the  cervical  canal,  fastened  by  a 
suture,  and  left  in  situ  until  healing  is  complete. 

Denudation  may  be  accomplished  by  scissors  or  scalpel,  the  patient 
being  in  the  Sims  or  lithotomy  position,  the  cervix  being  steadied  by 
tenaculum,  and  excessive  downward  traction  being  avoided.  Sutures 
may  be  of  silver  wire  (No.  27),  which  I  prefer,  or  of  silk-worm  gut 
silk,  or  chromicized  or  juniper  catgut.  They  may  be  removed  in  ten 
days,  the  patient  getting  up  about  the  fourteenth.  Careful  anti- 
sepsis.] 

The  various  plastic  operations  on  the  cervix,  amputation,  resection, 
suture  of  lacerations,  do  not  diminish  the  dilatability  of  the  part,  for 
they  heal  by  primary  cicatrization  without  the  formation  of  inelastic 
tissue.  Many  observations  agree  on  this  theoretic  point,  and  prove 
that  there  is  no  need  to  fear  sterility  or  dystocia.53 

Is  castration  a  legitimate  operation  in  metritis  ?  I  do  not  hesitate 
to  answer  in  the  negative.  Castration  owes  its  unquestionable  suc- 
cess, not  so  much  to  the  fact  that  it  was  done  for  disease  of  the 
uterus  as  for  characteristic  alterations  in  the  adnexa  (peri-oophoritis, 
perisalpingitis 54),  in  cases  of  old  or  badly  treated  metritis.  In  such 
cases  the  metritis  occupies  the  second  place,  and  the  treatment  relates 
more  especially  to  the  complication  which  has  become  the  principal 
disease.  But  to  practise  a  castration  with  removal  of  both  ovaries 
and  tubes  on  the  sole  indication  of  excessive  pain  during  the  menses, 
to  establish  thus  an  artificial  menopause,55  seems  to  be  too  extended 
an  application  of  the  operation.  In  a  number  of  the  reported  cases 
all  the  measures  of  conservative  surgery  do  not  appear  to  have  been 
exhausted  before  reaching  an  operation  which,  if  legitimate,  is  hardly 
indispensable. 

Pean 56  has  often  performed  vaginal  hysterectomy,  which  he  calls 
uterine  castration,  for  painful  metritis  accompanied,  as  he  says,  by 
the  morbid  state  described  as  utero-ovarian  neuralgia,  which  has 
resisted  all  medication.  In  such  cases  he  has  seen  ovarian  castration 
by  itself  permit  the  plains  to  continue,  as  if  the  uterus  were  a  centre 
from  which  reflexes  started  independent  of  those  which  take  their 
birth  in  the  adnexa.  On  the  contrary,  where  he  has  removed  the 
uterus  and  left  the  adnexa,  the  results  have  been  more  satisfactory. 
Pean,  then,  desires  to  substitute  vaginal  hysterectomy  for  Battey's 


TREATMENT   OF   METRITIS.  218 

operation  in  cases  of  chronic  and  painful  inflammation  of  the  utero- 
ovarian  apparatus;  he  recognizes  that  after  ablation  of  the  uterus, 
however,  one  may  be  obliged  to  open  the  abdomen  to  remove  the 
altered  adnexa,  which  are  difficult  to  reach  by  way  of  the  vagina. 
It  does  not  seem  to  me  proven  that  the  secondary  operation  has  not  a 
right  to  precede  the  principal  one,  which  it  has  often  rendered  need- 
less. Vaginal  hysterectomy  has  been  performed  many  times  by  other 
surgeons  for  rebellious  hemorrhagic  or  painful  metritis;  and  it  has 
certainly  been  abused.  The  most  recent  researches  demonstrate  that 
every  hypertrophic  glandular  metritis  which  has  resisted  curetting 
for  many  months  shows  thereby  its  tendency  to  become  an  epithe- 
lioma. These  growths  are  styled  adenoma  in  Germany,  and  form  the 
transition  between  hyperplasia  (benign  adenoma)  and  cancer  (malig- 
nant adenoma).  Exploration  by  the  curette  is  not  always  sufficient 
to  remove  doubt,57  for  we  are  not  able  thus  to  examine  the  glands  in 
all  their  depth.58  We  must  in  such  a  case  give  the  most  weight  to 
the  clinical  signs ;  in  any  case  we  may  well  be  cautious  about  oper- 
ating for  a  cancerous  tendency  in  metritis  when  there  is  no  actual 
degeneration  present. 

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43.  Aug.  Martin  :  Naturforscherversamudung  in  Cassel,  1878.  Cent.  f.  Gyn., 
18TS. 

44.  Marekwald  :    Arch.  f.  Gyn.,  Bd.  viii.,  p.  48 

45.  Schroder  :   Cbarite"  Annalen,  1878.     Zeitschr.  f.  Geb.  und  Gyn.,  hi.,  p.  419. 

46.  Rojeeki :  These  de  Paris,  1887,  No.  203.     Chanteloube  :  Thfese  de  Paris,  1888, 

Note  sur  l'Operation  d'Emmet.     Annales  de  Gyne"c,   October, 

Amer.  Jour.  Obstetrics,  October,  1888. 

Centr.  f.  Gyn.,  1888,  p.  769.     Fritsch:  Ibidem,  p.  804. 

:  American  Journal  of  Obstetrics  :   August,  1883,  June,  1884. 
New  York  Medical  Journal,  1887,  p.  693. 

Dechirure  Bilaterale  du  Col  chez  une  Femme  Enceinte.  Opera- 
tion d'Emmet  sans  Trouble  de  la  Grossesse.  International  Med.  Congress,  Wash- 
ington, September,  1887,  analyzed  in  Repertoire  Universel  de  Gyn6c.  et  d'Obst., 
1888,  p.  137  ;  Doleris  states  that  he  has  several  times  done  so  with  success. 

53.  Brooks  H.  Wells  :  The  Possible  Bangers  of  Trachelorrhaphy.  Amer.  Jour. 
Obst.,  June,  1884,  and  A.  Ducasse  :  De  la  Conception,  de  la  Grossesse  et  de  l'Ac- 
couchement  apres  la  Trachelorrhaphie  et  1'Amputation  du  Col  de  l'Uterus.  These 
de  Paris,  1889. 

54.  H.  Fritsch  :   Deutsche  Chirurgie,  Lieferung  56,  p.  343. 

55.  Kelly  :  American  Journal  of  Obstetrics,  xx.,  p.  180. 

56.  Pe"an  :  Indication  de  la  Castration  Uterine  et  de  la  Castration  Ovarienne. 
Gazette  des  Hopitaux,  1886,  p.  1,170,  and  Lecons  de  Clinique  Chirurg.,  vol.  vi.,  p. 
218,  1888. 

57.  Cornil  and  Brault :   Bull,  de  la  Soc.  Anat.,  January,  1888. 

58.  Valat :  De  FEpithel.  prim,  du  Corps,  etc.     Thesis,  Paris,  1889. 


No.  71. 

47. 

H  ouzel : 

November,  1888. 

4S. 

Hardon  : 

49. 

Sanger : 

50. 

Murphy 

51. 

Curtis  : 

52. 

Doleris : 

CHAPTER  Till. 


UTERINE   FIBROMATA. 


Pathology. — To  those  tumors  of  the  uterus  which  have  the  same 
structure  as  the  uterus  itself,  the  names  of  fibrous  body,  fibrous  tumor, 
myoma,  fibro-leiomyoma,  fibroid  (English  authors),  and  hysteroma 
(P.  Broca)  have  been  given.  They  are  usually  benign,  that  is  to  say, 
incapable  of  becoming  general  and  infecting  the  organism:  but,  while 
the  greater  number  of  them  may  exist  unnoticed,  causing  only  a 


Fig.  127.— Small  Interstitial  Fibroid,  a,  Hyper- 
trophied  uterine  wall;  b,  fibroid;  c,  uterine  mucosa 
showing  the  lesions  of  endometritis  with  polypoid 
vegetations. 


Fig.  128.— Submucous  Pediculated 
Fibroid. 


hidden  deformity  or  a  slight  infirmity,  there  are  many  which  are  of 
more  serious  import,  and  which  may  lead  to  conditions  resulting  in 
death. 

Histogeny. — Velpeau,  and  after  him  a  number  of  others,  attributed 
the  development  of  fibromata  to  the  presence  of  a  blood  clot  in  the 
uterine  tissue.1  The  spontaneous  organization  of  coagula  after  liga- 
tion of  arteries  suggested  the  idea  that  the  same  process  might  result 


UTERINE    FIBROMATA. 


217 


in  the  formation  of  these  neoplasms.  But  experimental  study  has 
demonstrated  that  this  organization  of  coagula  is  nothing  but  an  in- 
growth of  the  elements  of  the  vessel  wall,  and  thus  this  edifice  of 
theory,  founded  on  lack  of  observation,  collapses  altogether. 

Klebs 2  asserts  that  these  fibrous  tumors  have  their  origin  in  a  pro- 
liferation of  the  connective  tissue  and  the  muscular  layers  of  certain 
vessels;  the  different  nodules  thus  formed  become  aggregated  to  make 
one  tumor.     Klein  wachter  describes  the  evolution  of  fibromata  as  due 


Fig.  129.— Submucous  CEdematous  Fibroid  with  Hypertrophy  of  Uterine  Wall. 

to  a  round  cell  which  is  found  along  the  capillaries  and  produces  a 
partial  obliteration  of  them ; 3  these  cells  then  become  fusiform  and 
produce  the  nodules.  In  other  words,  our  knowledge  of  the  subject  is 
still  very  imperfect.' 

These  neoplasms  are  very  frequent;  according  to  Bayle,  who  de- 
scribed certain  anatomical  features  of  them  in  1813,4  a  fifth  of  all 
women  over  thirty-five  have  fibromata. 

The  number  is  very  variable ;  certain  uteri  present  an  enormous 
number  of  interstitial  or  pediculated  nodules.  Most  frequently 
there  are  three  or  four  distinct  tumors;  at  other  times  there  is  but 
one.  Though  clinically  there  may  appear  to  be  but  one,  not  rarely 
there  is  another  in  the  thickness  or  on  the  surface  of  the  organ, 


21S 


CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 


which  either  may  remain  latent  indefinitely  or  may  finally  develop ; 
this  fact  is  often  demonstrated  at  laparatomies. 

These  tumors  may  reach  very  large  proportions,  and  then  often 
become  fibro-cysts.  Stockard  found  one,  in  a  negress,5  that  was 
colossal,  weighing  one  hundred  and  thirty-five  pounds.  Even  the 
solid  tumors  may  be  as  large.  Hunter, 6  of  New  York,  recently  observed 
one  that  weighed  one  hundred  and  forty  pounds,  while  the  cadaver 
after  its  removal  weighed  but  ninety-five. 

The  body  of  the  uterus  is  more  often  affected  than  the  cervix.  The 
tumor's  position  relative  to  the  uterine  tissues  permit  us  to  distin- 
guish the  following  varieties : 


Fig.  ISO.— Subperitoneal  and  Interstitial  Fibroids  op  the  Fundus  of  the  Uterus.    (The  incisions  are 

to  show  the  multiple  nodules.) 

1.  Interstitial,  in  the  thickness  of  the  (usually  hypertrophied) 
muscular  parenchyma. 

2.  Submucous,  immediately  or  nearly  below  the  mucous  mem- 
brane. 

3.  Polypoid,  or  pediculated,  hanging  from  the  mucous  membrane 
by  a  stem  or  fold  of  the  mucosa,  with  muscular  fibres  and  vessels. 

4.  Subperitoneal,  external  to  the  muscular  tissue,  with  a  broad 
base  or  with  a  narrow  pedicle ;  it  is  well  not  to  speak  of  these  as 
polyps,  even  though  they  may  resemble  them,  but  to  keep  that  name 
for  those  which  are  found  within  the  cavity  of  the  organ.  An  im- 
portant sub-variety  is  the  intra-ligamentous,  developing  in  the  thick- 
ness of  the  broad  ligament,  which  will  be  described  with  tumors  of 
the  cervix. 

Whatever  may  be  the  seat  of  the  fibroma,  it  provokes  a  constant 
but  varying  degree  of  uterine  hypertrophy. 


UTERINE    FIBROMATA. 


219 


The  muscular  wall  increases  in  such  a  way  as  to  encapsulate  a 
number  of  tumors  as  a  single  mass ;  the  muscular  layers  then  resem- 
ble those  of  the  gravid  uterus,  often  being  continued  far  into  the 
broad  ligaments,  which  become  thickened  and  fleshy.7  A  large  vas- 
cular development  generally  accompanies  this  hypertrophy. 

The  increase  in  the  volume  of  the  uterus,  caused  by  the  continual 
congestion  of  which  the  neoplasm  is  the  focus,  might  be  compared  to 
that  which  occurs  in  the  first  months  after  fecundation;  for  which 
reason  the  name  fibrous  pregnancy  (grossesse  fibreuse)  has  been  pro- 


Fig.  131. — Interstitial  Fibroid  of  the  Body  op  the  Uterus. 

posed  by  Guy  on  to  designate  the  fact.8  Even  small  fibromata  are 
sufficient  to  produce  the  condition  (Fig.  127).  The  uterine  cavity  is 
found  much  enlarged  by  the  eccentric  hypertrophy,  and 'also,  in  part, 
by  the  traction  of  the  mass  which  hangs  from  the  fundus  of  the  organ. 

Fibromata  of  the  Cervix. — Fibrous  tumors  of  the  cervix  deserve  a 
special  paragraph ;  they  are  found  in  the  same  positions  and  could  be 
classified  as  other  fibroids ;  but  the  division  of  the  cervix  into  two 
distinct  regions,  the  supra-  and  the  sub-vaginal,  makes  another  classi- 
fication necessary. 

A.  Fibromata  of  the  External  Os. — Whether  submucous  or  inter- 
stitial, they  give  to  the  lip  involved  a  cylindrical  and  elongated  form 
(Fig.  134).  The  submucous  tumors  of  the  cervical  canal  occasionally 
take  on  a  peculiar  polypoid  form,  of  which  I  have  observed  examples. 


220 


CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 


They  descend  into  the  vaginal  canal  in  the  form  of  slender  stalactites 
or  like  the  drops  from  a  torch,  forming  a  kind  of  sheaf  which  appears 
at  the  external  os  and  is  attached  by  a  circular  or  semicircular  base 


Fig.  132.— Uterine  Polyp  Expelled  into  the  Vagina  but  Preserving  the  Triangular  Form  of  the 

Uterine  Cavity.  , 

at  the  level  of  the  isthmus  or  often  much  lower;  I  have  seen  a  sub- 
mucous cervical  fibroma  make  a  projection  in  the  interior  of  the 
dilated  cervix  like  a  plaited  collar  round  the  internal  orifice.     At 


Fig.  133.— Subperitoneal  Pediculated  Fibroid. 


other  times  these  little  polypi  contain  a  layer  of  glandular  tissue, 
newly  formed,  and  have  a  papillary  or  mulberry  appearance 9  (Fig.  135). 
Exceptionally  a  fibroma  within  the  uterine  wall  may  descend  into 
one  of  the  lips  of  the  cervix  by  a  kind  of  splitting  process.10 


uteri:; e  fibromata. 


221 


B.  Fibromata  of  the  Sub-vaginal  Portion. — The  only  forms  in  this 
class  which  deserve  special  mention  are  those  which  are  developed 
from  the  external  surface  of  the  region,  and  so  find  themselves  at  once 
between  the  layers  of  the  pelvic  floor.  They  usually  develop  behind 
the  cervix,  raise  the  pouch  of  Douglas,  and  come  into  contact  with  the 
posterior  wall  of  the  vagina  and  the  rectum.  They  often  pass  between 
the  layers  of  the  broad  ligament,  constituting  one  of  the  most  danger- 
ous of  the  intra-ligamentous  varieties.  They  may  even  exceed  these 
limits,  crowding  in  anteriorly  between  the  bladder  and  the  uterus, 
and  pushing  prolongations  as  far  as  the  iliac  meso-colon.  Imprisoned 
by  their  attachments  in  the  narrow  inclosure  of  the  bony  pelvis, 


Fig.  134.— Interstitial  Fibroid  of  the  Posterior  Lip  of  the  Cervix. 

which  is  itself  inextensible,  they  give  rise  to  the  most  serious  symp- 
toms by  compression ;  I  have  proposed  to  name  them  "  pelvic  fibro- 
mata." " 

Connection  of  Fibrous  Tumors  with  the  Uterine  Tissue. — 
Fibrous  tumors  have  usually  an  investment  of  loose  cellular  tissue 
which  forms  a  capsule,  out  of  which  they  can  be  shelled  with- 
out much  effort.  This  arrangement  is  at  times  so  well  marked  that, 
as  soon  as  the  capsule  is  incised,  the  tumor  projects  strongly,  under 
the  influence  of  the  muscular  contraction;  but  more  often  the  fibroma, 
instead  of  being  encased  in  the  uterine  parenchyma  like  a  foreign 
body,  is  held  in  place  by  the  fibrous  bands,  more  or  less  dense,  by 
which  its  vascular  connections  are  established.  There  are  also  rare 
cases  where  there  is  no  more  demarcation  between  tumor  and  uterus 


222  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

than  a  local  thickening  at  its  periphery.  In  general,  the  softer 
the  tumor  the  fewer  its  connections  with  the  neighboring  tissues. 

Structure  and  Texture.— To  the  naked  eye,  uterine  fibromata  are 
formed  of  dense  tissue,  shiny  or  rosy  white,  elastic,  giving  a  very 
clean  surface  on  section,  sometimes  unequally  convex,  as  if  the  mid- 
dle portions  were  compressed  by  the  superficial  layers,  generally  more 
closely  packed.  One  can  at  times  distinguish  on  the  surface,  with 
the  aid  of  a  glass,  the  intercrossing  loops  of  fibres  and  the  vortices, 
which  look  as  if  the  fibres  were  rolled  about  many  different  axes 
(Fig.  137). 

The  vessels  are  relatively  few;  but  in  tumors  of  great  size  we  do 
see  them,  superficially,  under  the  peritoneum  or  in  the  capsule,  and  I 


Fig.  135.— Small  Muriform  Polyp  op  the  Cervix.    (Papillary  fibroma  with  glandular  hypertrophy. 

Ackermann.) 

have  observed  in  one  case  a  vessel  of  the  broad  ligament  which  was  as 
large  as  the  brachial  and  had  given  a  loud  bruit  with  a  thrill.  The 
peripheral  veins  then  are  of  the  size  of  the  jugular,  adherent  on  all 
sides  to  the  muscular  bundles,  which  hold  them  wide  open.  When 
this  arrangement  is  very  well  marked  and  the  tumor  is  hollowed  by 
vascular  lacunae,  due  to  the  dilatation  of  the  capillaries,  we  have  the 
form  which  Yirchow12  calls  " teleangiectatic  myoma,"  or  "myoma 
cavernosum " ;  the  portions  thus  degenerated  resemble  a  sponge 
soaked  in  blood. 

In  polypi  the  pedicle  sometimes  contains  large  arteries.13  They 
present,  however,  a  thickness  of  their  walls  and  a  contractility  which, 
joined  to  the  elasticity  of  the  pedicle  itself,  secure  a  rapid,  sponta- 
neous haemostatic  action  as  soon  as  they  are  cut  off.     The  spaces 


UTERINE  FIBROMATA. 


223 


which  separate  the  different  layers  are  considered  by  Klebs  to  be 
lymph  channels. 

Nerves  have  been  followed  into  these  tumors  by  Astruc  and 
Dupuytren;  Bidder  has  demonstrated  them  anew,  and  Hertz  has  de- 
scribed their  mode  of  termination  in  the  nuclei  of  the  smooth  mus- 
cular fibres.14  On  microscopic  section  fibromata  present  smooth  mus- 
cular fibres  and  connective  tissue  in  varying  proportion.  According 
to  Ch.  Robin,  the  muscular  fibres  are  always  in  the  minority,  perhaps 
as  high  as  half  and  at  times  as  low  as  one-tenth.15  As  one  or  the 
other  predominates,  the  tumor  is  called  a  fibroma,  a  myoma,  or  a  fibro- 
myoma.     These  terms  are  not  exact  but  relative,  for  almost  always 


Fig.  136.— Intra-ligamentous  Fibroma.    A,  Abdominal  variety ;  B,  pelvic  variety. 

the  two  elements  are  mixed.  Gusserow16  proposes  to  distinguish 
them  as  hard,  where  the  connective  tissue  is  in  excess,  and  soft,  com- 
posed chiefly  of  muscular  fibres;  the  latter  form  is  seldom  entirely 
encapsuled  and  is  more  vascular.  On  section  we  see  the  fibres  cut 
transversely,  obliquely,  or  longitudinally.  The  first  are  easily  dis- 
tinguished by  the  fusiform  aspect  of  their  elements  and  the  char- 
acteristic nuclei  which  look  on  cross  section  like  a  mosaic;  this 
appearance  must  not  be  confounded  with  that  of  round  cells.  Be- 
tween the  bundles  there  are  fibrous  layers  of  unequal  thickness 
which  cross  in  all  directions ;  they  are  partly  connective  tissue,  poor 
in  cells,  and  partly  fusiform  bodies  prolonged  longitudinally  (Fig. 
138). 


224  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

Connections  with  Neighboring  Organs. — When  a  fibroma  with 
a  broad  base  grows  from  some  free  portion  of  the  uterus  (fundus,  an- 
terior or  posterior  surface),  it  extends  into  the  abdominal  cavity  above 
the  superior  strait  and  floats  among  the  intestines ;  the  uterus  is  then 
drawn  upward,  the  cervix  is  thinned  and  elongated. 

If  its  point  of  attachment  is  narrow,  the  tumor  may  fall  back- 
ward into  the  pouch  of  Douglas  and  become  fixed.  When  it  is  of 
large  size  and  not  bound  down  by  adhesions,  it  jolts  about  in  the 
abdomen,  irritating  the  peritoneum  till  it  provokes  an  exudation,  at 
times  liquid,  at  times  plastic,  which  forms  adhesions.  This  ascites 
is  generally  abundant  and  of  a  yellow  color,  rarely  tinged  with  blood, 
except  with  malignant  tumors.     A  form  of  ascites  has  been  observed 


mmm  wlmm  ■  BBS  1  :       ,: 
IB 


M 


i  iff 


:        11 

Fig.  137.— Uterine  Fibroid.    Section  showing  the  disposition  of  the  fibres  to  the  naked  eye. 

to  which  the  name  "  chylous  "  has  been  given;  it  is  probably  due  to  a 
transformation  to  fatty  granules  of  a  fibrinous  exudation.17 

Adhesions  when  present  are  usually  with  the  great  omentum  or 
the  intestine ;  a  loop  of  the  gut  may  be  so  fused  with  the  surface  of  a 
fibroma  as  to  defy  all  dissection.  These  adhesions  become  then  the 
lorincipal  source  of  derangement  of  nutrition,  and  the  pedicle  may  be- 
come so  thin  that-  the  tumor  ceases  to  grow.  It  may  even  break  off 
and  leave  the  fibroma  independent  of  the  uterus  and  grafted  on  some 
part  of  the  pelvic  circumference.  Huguier 18  and  Nelaton 19  have  re- 
ported cases  of  this  kind.  Depaul20  found  a  fibroma  entirely  free  in 
the  cul-de-sac  of  Douglas;  such  a  case  may  be  explained  by  the  rup- 
ture of  the  pedicle  with  absence  of  adhesions. 

Elongation  or  torsion  of  the  pedicle  may  cause  various  changes 
in  the  nutrition  of  the  tumor,  with  consecutive  degenerations. 


UTERINE   FIBROMATA. 


22c 


Alterations  and  Degenerations.— At  the  menopause  most  of  the 
fibromata  undergo  a  progressive  induration;  at  the  same  time  they 
diminish  in  volume  and  the  uterus  may  present  a  senile  involution 
and  atrophy;  the  tumor  still  persists,  but  without  causing  any  mor- 
bid reaction :  this  is  the  condition  of  most  of  these  tumors,  not  recog- 
nized during  life  and  found  for  the  first  time  at  the  autopsy  of  aged 
women. 

Calcification  is  an  unusual  change.  It  is  not  an  ossification,  as  the 
older  authors  thought;  the  deposits  of  carbonate  of  lime  are  found 
toward  the  middle  of  the  tumor,  sometimes  partially,  sometimes 
completely,  converting  it  into  a  uterine  stone.21  We  observe  this  but 
rarely  in  the  pedicled  subserous  form  or  in  polypi,  which  may  then  be- 


Fig.  138.— Uterine  Fibro-myoma.    Microscopic  view. 


come  free  and  be  expelled  spontaneously.  This  fact  has  been  known 
since  the  days  of  Hippocrates,  and  the  Academy  of  Surgery  has  col- 
lected a  number  of  such  cases.22 

Softening  may  result  from  various  causes.  During  pregnancy  the 
tumors  acquire  a  considerable  volume,  sharing  in  the  exaggerated 
nutrition  of  the  uterus.  Thus  swollen  with  juices  they  are  usually 
very  soft; 23  after  labor  and  by  a  process  attributed  a  little  hypotheti- 
cally  to  a  fatty  degeneration,  they  may  gradually  disappear,  taking 
part  in  the  uterine  involution.  Different  authors  have  cited  many 
cases  of  this  regression,  and  I  have  observed  it  in  one  very  remarkable 
instance ;  the  r^regnancy,  intervening  during  a  thermal  treatment  for  a 
large  fibroma,  had  doubled  the  size  of  the  tumor;  the  labor  took 
place  without  accident,  and  the  fibroma  disappeared  completely,  leav- 
ing no  traces. 

The  fatty  degeneration,  as  so  justly  remarked  by  Gusserow,  has 

15 


226  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

never  been  proven  by  the  microscope,  except  in  two  cases,  where 
there  was  no  diminution  in  the  size  of  the  tumor  as  the  result.24  Amy- 
loid degeneration  has  been  found  in  one  instacne  by  Stratz,  a  unique 
case  up  to  the  present.25  (Edema,  which  is  often  the  first  stage  of 
gangrene,  may  be  the  cause  of  the  softening. 

Colloid  or  myxomatous  degeneration,  according  to  Virchow,26  is 
characterized  by  the  effusion  of  a  mucous  fluid  between  the  muscular 
bands;  it  is  distinguished  from  simple  oedema  by  the  presence  of  the 
mucin  and  the  proliferation  of  nuclei  and  small  round  cells  in  the 
interstitial  tissue.  The  formation  of  fibro-cystic  tumors  may  succeed 
these  degenerations 27  when  the  bands  which  separate  the.  small  cells 
from  the  oedema  are  destroyed.  There  are  no  distinct  walls  in  these 
cysts,  as  they  are  formed  simply  from  the  lacunas  of  the  tumor  tissue. 

Other  fibro-cystic  tumors  have  a  very  different  origin  and  belong  in 
a  special  pathological  class.  These  cysts  are  formed  in  pre-existing 
cavities,  in  dilated  lymph  spaces  comparable  to  the  similar  dilatations 
which  the  blood-vessels  may  present.  The  fluid  which  they  contain 
is  limpid  and  coagulates  on  contact  with  the  air.  Leopold  has  termed 
these  tumors  "  lymphangiectatic  myomata." 28  It  must  be  noted  that 
this  lymphatic  origin  of  certain  cystic  tumors  of  the  uterus  had 
already  been  clearly  formulated  by  Koeberle.29  Their  formation  seems 
to  be  due  to  the  development  of  part  of  the  tumor  along  the  path  of 
the  lymph-vessels  contained  in  the  broad  ligament.  On  the  internal 
surface  of  such  tumors  we  can  demonstrate  an  einthelial  investment 
which  distinguishes  them  from  simple  cavities  formed  from  softening 
of  the  neoplasm  or  apoplexy  into  its  substance.  There  are  also  mixed 
forms  in  part  vascular  and  in  part  lymphatic.30 

We  must  be  careful  not  to  confound  these  tumors  of  the  uterus 
with  either  the  intra-ligamentous  ovarian  cysts,  which  are  very  adher- 
ent to  that  organ,  or  with  the  serous  accumulations  found  at  times  in 
foci  of  peritonitis  about  the  uterus ;  the  mistake  seems  to  have  been 
more  than  once  committed.  Certain  forms  of  pseudo-cysts  are  pro- 
duced in  the  foci  of  molecular  fatty  disintegration  at  the  centres  of 
large  tumors  where  the  nutrition  is  impeded.  There  can  be  no  gan- 
grene because  of  the  absence  of  germs ;  it  is  then  a  necrobiosis,  with 
the  formation  of  softNmasses,  which  later  may  fall  into  deliquescence 
and  fill  the  cavity  with  more  or  less  dense  fluid.  Hemorrhages  are 
often  added  to  dilute  the  contents  of  the  cyst  and  increase  their  size.31 
These  have  been  known  to  rupture  into  the  uterus.  In  certain  of 
these  rare  cases,  the  uterine  orifice  may  be  obliterated  by  the  elonga- 


UTERINE    FIBROMATA. 


227 


tion  of  the  cervix,  the  partial  rotation  of  the  organ,  and  a  certain  de- 
gree of  inflammation,  and  thus  is  formed  a  peculiar  form  of  hamia- 
tometra.  W.  A.  Meredith  lias  reported  a  remarkable  case  of  this 
condition  which  was  cured  by  supra-vaginal  hysterectomy;  the  mor- 
bid mass  weighed  fifteen  pounds  and  contained  five  pounds  of  blood.32 
Dubreuil 33  has  punctured  and  drained,  in  a  woman  of  sixty-five  years, 
an  hsematometra  that  simulated  a  fibro-cyst,  due  to  obliteration  of 


Fig.  139. — Pediculated  Fibroid  with  Abdominal  Evolution  (Schroeder).    MS,  Fibroid  lobe: 

M  C,  Fibro-cystic  lobe. 

the  neck  of  the  uterus  containing  a  fibroma ;  this  incomplete  opera- 
tion was  followed  by  death.  Tillaux 34  has  published  under  the  name 
"  cystic  uterus "  an  analogous  case,  which  was  cured  by  abdominal 
hysterectomy.  These  cases  are  usually  found  in  aged  patients,  where 
the  cervix  has  a  tendency  to  become  retracted  and  obliterated  under 
the  influence  of  senile  atrophy. 

It  is  evident,  then,  that  from  an  anatomical  point  of  view  these 


228  CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 

tumors  do  not  form  a  natural  group  of  myo-  and  fibro-cysts ;  for  they 
may  take  their  origin  from :  1st,  closed  spaces,  resulting  in  dilatation 
of  the  lymphatics,  or  lym|3hangiectasis  (Koeberle,  Leopold);  2d,  oede- 
matous  (Oscar,  Schroder)  or  myxomatous  infiltrations  (Virchow),  in 
their  highest  development ;  3d,  lacuna?  (geodes)  formed  at  the  centre 
of  myomatous  or  sarcomatous  tumors  by  disintegration  of  their 
tissue.  Apoplectic  foci  may  complicate  either  of  these  different 
varieties. 

Inflammation  ;  Suppuration  ;  Gangrene. — It  is  probable  that  the 
starting-point  for  inflammation  in  fibrous  tumors  is  always  a  morti- 
fication, more  or  less  extended,  which  infects  the  capsule  and  sets  up 
a  suppuration  in  the  zone  where  the  tissue  is  both  more  lax  and  more 
vascular.  This  initial  mortification  may  be  due  to  surgical  interfer- 
ence, which  has  opened  the  seat  of  the  fibroma  with  a  therapeutic 
object,  or  to  an  infection  from  outside  following  septic  exploration 
(dilatation,  sounding,  etc.) ;  or,  finally,  it  may  come  from  compression 
and  obliteration  of  the  nutritive  vessels  of  the  tumor,  with  chafing  of 
the  mucous  membrane  which  covers  and  protects  it  against  the  en- 
trance of  germs.  The  latter  mode  of  origin  is  especially  frequent  in 
polypi.  If  it  is  true  that  a  mortification  of  a  small  part  of  the  tumor, 
interstitial  or  submucous,  precedes  inflammation  and  suppuration,  it 
is  due,  on  the  other  hand,  to  the  agency  of  this,  in  its  turn,  that  the 
whole  mass  becomes  gangrenous,  and  separates,  by  an  actual  dissec- 
tion, from  the  adjacent  tissues. 

The  sphacelated  portions  are  eliminated  spontaneously  or  by  the 
aid  of  art ;  or  they  may  produce  a  putrid  infection.  The  pus  may 
spread  itself  out  in  the  pelvic  cellular  tissue.  G.  Braun 35  reports  a 
case  where  the  pus,  after  distending  the  uterine  cavity,  discharged  by 
the  external  os  and  also  through  the  inguinal  region.  Orthmann 36 
performed  an  unsuccessful  laparatomy  on  a  woman  in  whom  a  sup- 
purating fibroma  had  perforated  the  posterior  uterine  wall  and  caused 
peritonitis. 

Cancerous  Degeneration. — Can  a  carcinoma  arise  from  a  fibroma? 
Simpson  maintained  that  the  irritation  produced  by  a  fibroma  invited 
the  formation  of  malignant  neoplasm ;  to-day  we  express  the  same  idea 
by  saying  that  its  presence  constitutes  a  locus  minoris  resistentice, 
producing  the  local  determination  of  the  diathesis.  Recent  researches 
allow  us  to  form  a  definite  idea  of  the  process.  It  is  probable37  that- 
in  certain  cases  it  is  the  chronic  inflammation  which  involves  the 
mucous  membrane  and  is  the  constant  accompaniment  of  fibromata, 


UTERINE   FIBROMATA.  229 

which  first  causes  a  proliferation  of  the  glands ;  this,  at  the  beginning 
of  a  typical  form  (adenoma),  passes  to  the  atypical  and  becomes  epi- 
theliomatous.  E.  Wahrendorff 38  collected  in  Schroeder's  clinic  four 
such  cases  which  seem  conclusive.  A  second  way  in  which  cancer 
may  arise  from  a  fibroma  is  by  sarcomatous  degeneration  of  the  frame- 
work of  the  tumor,  which  is  little  by  little  infiltrated  with  round  cells 
until  the  muscular  fibres  disappear.  It  is  also  possible  that  these 
myo-sarcomata  undergo  a  cystic  transformation,  either  by  softening 
and  hemorrhages  or  by  distention  of  the  lymph  spaces.  There  is  then 
a  sarcomatous  variety  of  fibro-cyst. 

As  to  the  degeneration  of  a  fibroma  into  carcinoma,  it  is  evident  from 
Gusserow's  inquiry  into  the  subject  that  it  is  far  from  being  demon- 
strated. The  observations  cited  to  prove  the  point  have  to  do  gener- 
ally with  cancer  invading  the  uterus  by  the  side  of  a  fibroma,  which 
is  a  very  different  thing  from  the  pathological  and  pathogenic  stand- 
point, however  much  like  it  it  may  be  clinically.  C.  Liebmann 39  has 
lately  published  a  case  where  it  seems  certain ;  there  was  also  cancer 
of  both  ovaries. 

The  association  of  cancer  of  the  cervix  with  fibroma  of  the  body  is 
not  infrequent. 

Adjacent  and  Distant  Lesions.— Wyder40  and  Von  Campe  have 
shown  that  in  almost  all  cases  of  fibroma  there  is  present  also  an 
endometritis:  the  mucous  membrane  of  the  uterus  suffers  a  glandular 
or  interstitial  hyperplasia.  Wyder41  has  observed  that  the  former  is 
found  almost  exclusively  where  the  tumor  is  at  a  distance  from  the 
uterine  cavity,  and  the  interstitial  occurs  with  those  but  little  re- 
moved from  the  mucous  membrane;  occasionally  we  encounter  a 
mixed  form,  which  Olshausen  calls  "  endometritis  fungosa."  These 
lesions  explain  the  symptomatic  hemorrhages  of  fibromata. 

It  is  certain  also  that  there  exists  in  some  cases  an  endosalpingitis 
by  propagation;  for  at  times,  in  hysterectomies  and  castration  for 
fibroma,  the  tubes  are  found  flexuous  and  full  of  blood.  Rose,42  in 
the  course  of  a  myomotomy,  discovered  one  of  these  hsematomata  of 
the  tube,  which  was  so  thinned  that  rupture  seemed  imminent,  and 
he  cites  this  condition  among  the  indications  for  operation. 

Bantock 43  finds  that  in  patients  with  uterine  fibroma  the  liver  is 
fatty,  and  attributes  the  lesion  to  the  presence  of  the  tumor;  he  be- 
lieves it  to  be  a  frequent  cause  of  unsuccessful  operation.  Fibrous 
uterine  tumors,  by  pressure  on  the  ureters,  may  produce  grave  kidney 
disorders — pyelitis,  pyelonephritis,  hydronephrosis.44    These  accidents 


230  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

are  especially  frequent  when  the  tumor  has  a  pelvic  development; 
I  will  describe  them  with  cancer. 

Lesions  of  the  heart,  which  may  be  found  in  all  cases  of  large 
abdominal 45  tumor,  are  very  often  a  complication  of  uterine  fibroma. 
They  seem  at  times  dependent  upon  renal  changes,  as  Traube  has  in- 
dicated, but  often  we  cannot  find  any  such  correlation.  The  hyper- 
trophy, with  or  without  dilatation  of  the  cavities  or  consecutive 
change  in  the  cardiac  tissue,  produces  itself,  no  doubt,  by  a  pathogeny 
similar  to  that  which  causes  the  hypertrophy  in  pregnancy.  As  to 
the  final  degeneration  of  the  heart,  it  is  strongly  favored  by  the 
anaemic  and  cachectic  condition  of  certain  subjects;  two  such  forms 
of  degeneration  are  described,  the  fatty  and  brown  atrophy  of  the 
myocardium  (Hofmeier).  Sebileau 46  has  very  recently  called  attention 
to  the  troubles  caused  by  hypertrophy  and  dilatation  of  the  left  side 
of  the  heart,  more  rarely  of  the  right,  in  voluminous  tumors  of  the 
abdomen. 

BIBLIOGRAPHY. 

1.  Velpeau  :  Diet,  in  30  vols.,  vol.  xxvi.,  p.  173,  Paris,  1842. 

2.  Klebs  :   Handbuch  der  pathol.  Anatoinie,  i.,  Berlin,  1873. 

3.  Kleinwackter:  Zeitschr.  f.  Geb.  und  Gyn.,  Bd.  ix. 

4.  Bayle  :  Diet,  in  20  vols.,  vol.  vii. 

5.  Stockard  :  Med.  Record,  Aug.  16th,  1884. 

6.  Hunter:    Amer.  Jour.  Obst.,  xxi.,  p.  62. 

7.  Charles  Labbe:  De  l'Hypertrophie  Totale  de  rUterus.  Archives  G6n6r.  de 
Medecine,  1885,  p.  257. 

*  8.  F.  Guy  on  :    Des  Tumeurs  Fib  reuses  de  rUterus.     These  d'Agreg.,  Paris, 
1860,  and  Tillaux,  Gaz.  des  Hopit.,  1867,  No.  144,  cites  a  curious  instance  of  it. 

9.  Ackermann  :   Virchow's  Archiv,  Bd.  xliii.,  p.  88. 

10.  Ducheniin  :  Quelques  Considerations  sur  les  Tumeurs  Fibreuses  de  l'Ut6rus, 
Strasbourg,  1863. 

11.  S.  Pozzi:  De  la  Valeur  de  FHysterectomie  dans  le  Traitement  des  Corps 
Fibreux  de  l'Uterus.     These  d'Agregation,  Paris,  1875. 

12.  Virchow  :  Traite  des  Tumeurs,  vol.  iii. 

13.  Turner  :  Edinburgh  Medical  Journal,  1861,  p.  706. 

14.  Hertz:  Virchow's  Archiv,  vol.  xlvi.,  p.  235. 

15.  Ch,  Robin:  Diet,  de  Nysten,  14th  ed.,  Paris,  1878. 

16.  Gusserow  :  Die  Neubildungen  d.  Uter.,  1886,  page  56. 

17.  TerriUon  :  Bull,  de  la  Soc.  de  Chir.,  July,  1888,  and  Letulle  :  Rev.  de  M6d., 
1884,  page  722,  and  1885,  page  973. 

18.  Huguier  :  Gaz.  des  Hop.,  1860,  page  411. 

19.  Ne4aton  :  Gaz.  des  H6p.,  1862,  page  77. 

20.  Depaul :  Bull,  de  la  Soc.  Anat.,  xix.,  page  15. 

21.  Everett:  Amer.  Jour.  Obst.,  vol.  xii.,  page  700,  has  collected  33  cases  of 
calcification  of  fibroid  tumors.  See  also  Ibid.,  vol.  xiv.,  p.  108;  vol.  xx.,  p.  103; 
also  Lenhardt :  Zeit.  f.  Geb.  u.  Gyn.,  Bd.  iii.,  page  359. 

22.  Louis:  M6moires  de  TAcad.  de  Chirurgie,  1753,  vol.  ii.,  p.  120. 


UTERINE   FIBROMATA.  231 

23.  Doleris  :  Archives  de  Tocologie,  January  and  February,  1883. 

24.  Freund  :  Klin.  Beitrage  f.  Gynak.,  iii.,  p.  152.  A.  Martin :  Beitrage  zur 
Geburtsh.,  etc.,  Berlin,  1874,  p.  34. 

25.  C.  H.  Stratz  :  Zeitschr.  f.  Geb.  und  Gyn.,  Bd.  xvii.,  Heft  1,  1889,  p.  80. 
20.  Virchow:  Traits  des  Tumeurs,  vol.  iii.     Bulletins,  1887,  p.  489. 

27.  Oskar  Schroder:  UeberCystofibroide  des  Uterus,  Strasbourg,  1873.  Lebec: 
Etude  sur  les  Tumeurs  Fibro-kystiques  de  l'Uterus.     These  de  Paris,  4880. 

28.  Fehlingand  Leopold:  Archiv  f.  Gyn.,  Bd.  vii.,  p.  331. 

29.  Koeberle"  :   Gaz.  hebdoin.,  February,  1869. 

30  W.  Mtiller:  Beitrage  zur  Kenntniss  der  cystoiden  Uterustumoren.  Archiv 
f.  Gynak.,  Bd.  xxx.,  Heft  2. 

31.  L.  Championniere  :   Bull,  de  la  Soc.  de  Chir.,  1889,  p.  196. 

32.  Meredeth  :  Trans.  Obst.  Soc,  London,  Nov.  2d,  1887. 

33.  Dubreuil :  H6matometrie.     Rev.  de  Chir.,  Aug.,  1889. 

34.  Tillaux  :  Uterus  Kystique.     Ann.  de  Gyn.,  July,  1889. 

35.  Braun  :   Zur  Behand.  d.  Uterus  Fib.     Wien.  Med.  Zeit.,  No.  100,  1867. 

36.  Orthmann  :   Centr.  fur  Gyn.,  1886,  p.  737. 

37.  Schroder  :  Mai.  des  Org.  G6n.  de  la  Fern.,  French  ed.,  1886,  p.  238. 

38.  E.  Wahrendorff  :  Fibromyome  und  Carcinome  des  Uterus.  Dissert.  Inaug., 
Berlin,  1887. 

39.  C.  Liebman  :  Ein  Fall  von  Myocarcinoni  des  Uterus.  Centr.  f.  Gyn.,  1889, 
No.  17. 

40.  Wyder  :  Beitrage  zur  normalen  und  path.  Histol.  der  Uterusschleimhaut. 
Arch.  f.  Gyn.,  1878,  Bd.  xiii.,  p.  35.  Von  Campe  :  Verhandl.  der  Berlin.  Gesellsch. 
f.  Geb.  und  Gyn.,  January,  1884.     Zeitschr.  f.  Geb.  und  Gyn.,  Bd.  x.,  p.  351,  1884. 

41.  Wyder :  Die  Mucosa  Uteri  bei  Myomen.  Archiv  f.  Gyn.,  1887,  Band  xxix., 
p.  38. 

42.  E.  Rose :  Ueber  die  Nothwendigkeit  der  Myomoperationen.  Deutsche 
Zeitschr.  f.  Chir.,  Bd.  xxv.,  Heft  4  and  5. 

43.  Bantock :  British  Gynrecolog.  Journal,  1887,  vol.  ii.,  p.  84. 

44.  S.  Pozzi :  De  la  Valeur  des  Alter,  des  Reins  pour  les  Indications  de  l'Hys- 
terectomie.     Annales  de  Gynecol.,  July,  1884. 

45.  Hofmeier  :  Zur  Lehre  von  Shock.  Zeitschr.  fur  Geb.  und  Gyn.,  Bd.  xi.,  p. 
366.  Bedford  Fenwick  :  On  Intra-abdominal  Tumors  as  a  Cause  of  Cardiac  De- 
generation.    The  British  Gynaecological  Journal,  May,  1887,  vol.  ii.,  p.  72. 

46.  Sebileau  :  Le  Coeur  et  les  Grosses  Tumeurs  de  1' Abdomen.  Rev.  de  Chir., 
1888,  p,p.  284.  369. 


CHAPTER  IX. 

SYMPTOMS,   DIAGNOSIS,   AND   ETIOLOGY   OF   UTERINE 

FIBROMATA. 

The  symptoms  of  fibroma  of  the  uterus  are  of  two  kinds:  1st,  the 
rational  signs,  which  reproduce  the  uterine  syndroma  described  in 
Chapter  VI.,  with  certain  special  differences  and  a  predominance  of 
the  hemorrhage;  2d,  the  physical  signs  proper  to  the  tumor. 

1.  Rational  Signs. — The  completeness  of  my  description  of  the 
uterine  syndroma  permits  me  to  abridge  this  section.  The  hemor- 
rhages appear  in  a  peculiar  form  and  become  the  chief  symptom  in 
the  majority  of  these  cases.  They  occur  either  as  metrorrhagia  or 
as  menorrhagia ;  that  is,  they  come  at  the  regular  period  of  menstrua- 
tion or  during  the  intervals.  They  are  intimately  connected  with  the 
lesion  of  interstitial  metritis,  which  always  accompanies  fibroma  situ- 
ated at  but  little  distance  from  the  mucous  membrane ;  the  glandular 
metritis  which  is  found  with  tumors  farther  removed  from  the  uter- 
ine cavity  gives  rise  only  to  leucorrhoea.  In  general  the  symptom  of 
bleeding  is  more  complained  of  the  more  the  neoplasm  invades  the 
cavity  and  reaches  its  highest  grade  in  polypi.  The  loss  of  blood  is 
very  enfeebling  to  the  patient,  but  death  by  hemorrhage  is  excep- 
tional: Duncan  has  reported  one  such  case  where  at  the  autopsy  a 
rupture  of  a  large  uterine  sinus 1  was  found. 

The  leucorrhoea  is  not  distinctive;  at  times  there  may  be  very 
abundant  serous  discharges,  a  hydrorrhea,  which  differs  from  that 
of  cancer  in  having  no  odor  and  in  being  intermittent. 

The  pains  are  various.  There  is  usually  only  a  sensation  of  drag- 
ging and  weight,  with  reflex  neuralgias  in  the  lumbar  region  and 
abdomen,  as  is  so  common  in  any  uterine  affection.  To  these  are 
joined,  when  the  tumor  projects  into  the  uterine  cavity,  colic  and 
expulsive  pains  occurring  at  the  time  of  the  hemorrhages.  When  the 
tumor  is  very  large,  it  may  press  upon  the  sacral  plexus  and  cause 
extreme  sciatic  pain,2  which  is  apt  to  be  more  violent  at  the  menstrual 
period.  Jude  Hue 3  observed  one  case  of  this  kind  where  the  sup- 
port of  an  air  pessary  caused  the  sciatica  to  disappear. 

The  symptoms  of  vesical  compression  are  very  frequent;   West 


SYMPTOMS   OF   UTERINE   FIBROMATA.  233 

found  dysuria  in  thirty-five  cases  out  of  eighty-six,  but  Gallard  did 
not  regard  this  as  simply  a  mechanical  trouble,  although  he  gave  no 
explanation  of  its  production.4  It  is  probable  that  this  dysuria  is 
due  to  small  tumors  on  the  anterior  face  of  the  uterus  .in  direct  rela- 
tion with  the  neck  of  the  bladder.5  All  these  visceral  symptoms  are 
more  pronounced  during  the  periodical  congestion  of  menstruation, 
and  they  may  at  times  acquire  the  importance  of  a  cystitis  from  the 
permanent  presence  of  residual  urine  or  from  infection 'introduced  by 
the  catheter  when  proper  precautions  are  not  observed.  The  compres- 
sion of  the  vesical  neck  may  produce  a  chronic  distention  which  sim- 
ulates ovarian  cyst.6 

The  compression  of  the  rectum,  more  rare  than  the  preceding,  may 
at  times  cause  hemorrhoids,  and  with  the  dyspepsia  will  produce 
constipation.  Barnes 7  attributes  great  importance  to  the  absorption 
of  excrementitious  matters  which  follows  this  obstinate  constipation, 
and  considers  it  a  veritable  toxsemia,  which  he  proposes  to  call  coprse- 
mia ;  recent  researches  on  the  ptomaines  and  leucomaines  give  a  cer- 
tain weight  to  this  opinion,  which  seemed  a  very  bold  one  when  it 
was  first  formulated. 

Fibromata  which  are  contained  within  the  lesser  pelvis  may  cause 
internal  strangulation  and  death.8 

Compression  of  the  ureters  and  grave  renal  troubles  have  been 
known  since  Murphy's  description  of  them ; 9  since  which  time  there 
have  been  numerous  observations  of  this  kind  scattered  through  the 
literature  of  the  subject.  I  have  collected  some  of  these  and  showu 
that  the  risk  of  this  serious  complication,  wrongly  considered  rare  by 
Gallard 10  as  by  most  other  authors,  should  on  the  contrary  be  one  of 
the  most  serious  indications  for  operation.11 

A  very  great  number  of  the  deaths  following  hysterectomy  or  cas- 
tration must  be  attributed  to  renal  degeneration,  by  reason  of  which 
the  surgical  interference  and  the  long  inhalation  of  the  anaesthetic 
are  invested  with  great  and  sudden  gravity.  (See 12  reports  a  case  of 
pregnancy  at  four  and  one-half  months  with  three  fibromata,  of  the 
size  of  an  apple,  compressing  the  bladder;  the  fundus  imprisoned,  the 
cervix  above  the  symphysis;  unsuccessful  attempts  to  disengage; 
death;  and  at  the  autopsy,  pyelo -nephritis.  Skene,  on  this  occasion, 
said  that  it  was  the  third  fatal  case  of  pyelo-nephritis  which  he  had  seen 
from  pressure  on  the  vesical  neck,  and  that  such  cases  were  probably 
more  frequent  than  was  supposed.  Salin  and  Wallis 13  report  a  case 
of  castration,  with  death,  from  double  hydronephrosis,  due  to  a  large 


234  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

uterine  myoma  in  a  woman  of  forty  years,  who  had  always  suffered 
great  pain  in  the  dorsal  decubitus.  The  castration  was  followed  by 
suppression  and  death  in  seven  days,  with  the  symptoms  of  uraemia 
and  a  little  albumin  in  the  urine.  At  the  autopsy  the  ureters  were 
found  compressed  and  thickened,  their  pelves  dilated).  On  the  other 
hand,  symptoms  of  pyelitis,14  and  of  albuminuria  with  threatening 
uraemia,15  have  been  seen  to  disappear  after  the  removal  of  a  fibroma 
which  compressed  the  ureters.  We  must  never  neglect  to  examine 
the  urine,  both  chemically  and  by  the  microscope,  and  determine  the 
proportion  of  urea,  the  presence  of  albumin  or  pus,  and  the  character- 
istic hyaline  and  granular  casts. 

Every  abdominal  tumor  causes  an  increased  vascular  pressure.,  and 
so  reacts  upon  the  cardiac  muscle.  It  is  not  therefore  astonishing 
that  any  heart  lesion,  although  slight,  may  be  aggravated  by  the 
presence  of  a  fibroid;  for  a  similar  effect  is  produced  by  pregnancy.16 
A  part  of  the  cardiac  trouble  observed  in  patients  with  voluminous 
tumors  of  this  kind  may  then  be  due  to  this  origin ;  but  the  compli- 
cation is  far  too  frequent  to  be  always  explicable  in  such  a  way.  Only 
a  few  isolated  observations  have  been  published,17  since  Hofmeier,13 
in  1884,  in  an  article  remarkable  for  its  physiological  and  pathologi- 
cal explanation  of  shock,  insisted  on  the  frequency  of  cardiac  disease 
in  cases  of  abdominal  tumor,  and  especially  with  fibromata  of  large  size. 
He  collected  a  series  of  eighteen  cases  where  sudden  death  was  caused 
by  cardiac  failure  provoked  by  the  presence  of  a  large  abdominal 
tumor,  either  physiological  or  pathological;  in  three  of  these  there 
was  advanced  fatty  degeneration  of  the  heart  muscle  (two  myomata 
and  one  ovarian  cyst)  and,  in  fifteen,  brown  atrophy  of  it  (five  ovarian 
tumors,  five  myomata,  and  five  pregnancies).  Five  deaths  occurred 
before  any  operation,  nine  after  operation,  and  five  following  labor. 

This  interesting  question  has  been  studied  by  other  authors  also. 
Fehling,19  in  a  series  of  fourteen  hysterectomies,  studied  all  the  pa- 
tients from  this  point  of  view,  and  found  in  four  of  them  manifest 
signs  of  cardiac  alteration.  He  also  observed  at  the  same  time  three 
cases  of  fibroma  of  middle  size,  with  symptoms  of  heart  disease ;  two 
of  these  patients  died  afterward,  one  of  them  suddenly.  In  America, 
Dower20  published  an  observation  of  this  kind;  and  in  England,  B. 
Fen  wick 21  presented  to  the  Gynaecological  Society  of  London  a 
memoir  upon  the  subject.  In  France,  Sebileau 23  collected  confirma- 
tory cases.  Among  eighteen  cases  of  tumor  of  the  abdomen  which  he 
observed  in  reference  to  this  point,  seventeen  had  cardiac  trouble  indi- 


SYMPTOMS    OF   UTERINE   FIBROMATA.  *  235 

cated  by  a  murmur;  but  in  the  three  cases  of  myoma  which  he  cites 
there  was  no  autopsy.  We  should,  then,  auscultate  carefully  every  pa- 
tient with  a  tumor  of  any  considerable  size ;  the  dull  character  of  the 
heart  sounds,  the  dyspnoea,  and  the  general  debility  may  lead  us  to 
fear  a  fatty  degeneration  of  the  myocardium.  Brown  atrophy  may 
not  give  any  special  symptoms ;  it  is  found  chiefly  in  individuals  who 
are  much  weakened  by  hemorrhages. 

I  share  in  the  opinion  of  those  surgeons  who  see  in  this  lesion  a 
new  indication  for  operation  and  at  the  same  time  a  grave  addition  to 
the  prognosis. 

Among  the  signs  furnished  by  local  examination,  that  which  is 
common  to  all  tumors,  whether  large  or  small,  should  be  given  the 
first  place,  namely,  elongation  of  the  uterine  cavity.  This  is  constant 
in  all  tumors  during  their  evolution ;  that  is,  all  giving  rise  to  morbid 
phenomena.  The  uterus  is  dilated  both  with  a  small  interstitial 
fibroma  and  with  a  small  polyp,  since  it  is  hypertrophied  under  the 
influence  of  what  Guyon  has  called  the  "fibrous  pregnancy."  With 
a  large  fibroma  the  uterus  is  also  elongated  by  the  eccentric  develop- 
ment of  th«  tumor,  and  the  traction  which  it  causes  upon  the  cervix ; 
the  sound  may  pass  as  far  as  twenty  centimetres  (eight  inches). 

This  passage  of  the  uterine  sound  should  always  be  done  with  the 
greatest  care;  it  is  generally  possible  to  use  a  silver  instrument  which 
one  can  curve  as  is  necessary.  But  for  fear  of  meeting  difficulties  we 
may  employ  a  urethral  bougie  which  is  moderately  flexible,  seizing  it 
close  to  the  cervix  to  determine  how  far  it  has  penetrated.  This  sim- 
ple instrument  is  preferable,  I  think,  to  Caulet's  metallic  hystero- 
meter  or  to  Terillon's  hystero-curvimeter. 

The  uterine  cavity  may  be  effaced  by  a  tumor  which  projects  into 
it,  and  the  sound  may  not  pass. 

The  search  for  the  tumor  should  be  made  by  bimanual  palpation, 
aided  by  rectal  touch ;  and  in  difficult  cases  it  may  be  well  to  admin- 
ister an  anaesthetic,  to  relax  the  abdominal  walls.  One  general  remark 
is  applicable  to  all  these  examinations — they  furnish  very  variable 
information,  according  as  they  are  made  during  or  after  a  fluxionary 
or  hemorrhagic  period.  In  the  second  case  we  often  find  a  great 
diminution  in  the  size  of  the  tumor,  which  might  cause  mistakes  as 
to  the  internal  treatment  to  be  followed.  We  must  be  on  our  guard 
as  to  the  contractions  which  some  have  claimed  to  feel  in  certain  of 
these  tumors;  a  fibrillary  movement  of  the  abdominal  walls,  the  glid- 
ing of  a  loop  of  the  intestine,  might  easily  give  rise  to  this  illusion. 


236  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

When  the  tumor  has  effaced  or  passed  beyond  the  cervix  it  is 
accessible  to  vaginal  touch. 

Diagnosis. — From  a  clinical  point  of  view  we  may  divide  these 
fibrous  bodies  into  three  great  classes,  according  as  the  tumor  (1)  is 
very  small  and  interstitial  or  (2  and  3)  is  well  characterized  and  pur- 
sues its  evolution  toward  the  peritoneal  or  the  uterine  cavity.1  In 
the  first  case  the  chief  symptoms  are  those  of  the  complicating  metri- 
tis, the  metritic  type. 

In  the  second  form,  with  a  vaginal  evolution,  we  must  distinguish 
the  varieties  caused  by  A,  submucous  fibroma  of  the  body;  B,  pedic- 
ulated  fibroma  of  the  body,  or  polypi ;  C,  fibroma  of  the  external  os, 
or  of  the  sub-vaginal  portion  of  the  cervix. 

In  the  third  case,  with  an  abdominal  evolution,  we  must  distin- 
guish, A,  pediculated  fibroma ;  B,  those  developed  at  the  fundus  above 
the  attachment  of  the  broad  ligaments ;  C,  those  from  the  body  of  the 
organ  below  the  attachment  of  the  broad  ligaments ;  and,  among  these 
last,  D,  those  of  the  sub-vaginal  portion  of  the  cervix  below  the  peri- 
toneum which  have  a  pelvic  development  in  the  tissues  of  the  lesser 
pelvis.     The  following  table  renders  this  clear: 

I.  Metritic  type.— Small  interstitial  fibroma. 

II.  Type  of  vaginal  evolution : 

A.  Fibroma  of  the  external  os — sessile  or  pedicled. 

B.  Submucous  fibroma  of  the  body. 

C.  Fibroma  of  the  body,  pedicled  or  polypi. 

a.  Intra-uterine. 

o.  With  intermittent  signs. 

c.  Intra-vaginal — var.  enormous  polypi. 

III.  Type  of  abdominal  evolution — subperitoneal  or  interstitial : 

A.  Pedicled  fibroma. 

B.  Sessile  fibroma,  not  in  the  broad  ligaments. 

C.  Sessile  fibroma,  in  the  broad  ligament : 

a.  Abdominal. 
o.  Pelvic. 

I.  Diagnosis  of  Fibroma  of  the  Metritic  Type. 

Small  Interstitial  Fibroma. — When  the  tumor  is  not  very  large 
and  has  no  tendency  to  project  from  the  uterine  wall  (Fig.  127)  it  is 
at  times  very  difficult  to  recognize  the  real  source  of  the  morbid 
phenomena  observed,  the  chief  of  which  would  be:  persistent  hemor- 


DIAGNOSIS   OF   UTERINE   FIBROMATA.  237 

rhage  coincident  with  enlargement  of  the  uterine  cavity,  and  finally 
the  discovery  of  a  tumor. 

We  must  eliminate  hemorrhagic  metritis.  Early  pregnancy  is 
accompanied  by  cessation  of  the  menses,  but  we  should  remember 
that  in  exceptional  cases  they  have  persisted.  Abortion  with  delay 
in  the  involution  of  the  uterus  caused  by  retention  of  placental 
fragments,  is  distinguished  by  its  special  course  and  by  the  study 
of  the  material  furnished  by  the  curette.  Cancer  of  the  uterus 
is  also  accompanied  by  hemorrhage,  but  with  this  there  is  foetid 
leucorrhcea,  and  the  curette  will  remove  fragments  which  under  the 
microscope  determine  the  nature  of  the  tumor.  Inflammations  of 
the  tubes  and  ovaries  are  a  frequent  source  of  error,  for  there  may 
be  repeated  hemorrhages,  and  a  tumor  (hydro-,  hemato-,  or  pyo- 
salpinx)  which  appears  to  form  part  of  the  uterus,  attached  either 
to  the  sides  of  the  organ  or  to  the  posterior  surface  in  Douglas'  pouch. 
We  cannot  always  in  our  search  determine  the  presence  of  fluctua- 
tion, and  it  is  dangerous  to  examine  for  it  with  too  much  zeal ;  in  the 
small,  tense  tumors  it  is  generally  absent.  The  very  great  rapidity 
of  the  formation,  the  patient's  own  story,  the  rational  signs,  careful 
local  examination  under  the  influence  of  anaesthetics,  and  the  absence 
of  increase  in  the  size  of  the  uterus  are  all  valuable  means  for  recog- 
nizing disease  of  the  adnexa. 

Anteflexion  and  retroflexion,  although  accompanied  by  bleeding, 
do  not  deceive  us  for  very  long;  the  nature  of  the  tumor  which  we 
feel  in  the  cul-de-sac  on  one  side  or  the  other  of  the  vagina  should  be 
quickly  recognized  by  the  sound  and  bimanual  palpation.  The  small 
collections  of  f seces  which  are  found  in  the  rectum  and  felt  by  vaginal 
touch  need  only  be  called  to  mind  in  order  to  dismiss  them ;  they 
could  deceive  no  one  but  a  novice.  The  finger  indents  them  and  a 
purgative  causes  them  to  disappear. 

II.  Diagnosis  of  Fibroma  with  a  Vaginal  Evolution. 

A.  Of  the  External  Os. — The  existence  of  a  tumor  hanging  from 
the  lip  of  the  cervix  is  here  the  capital  symptom.  Ordinarily  it  is 
not  ulcerated,  but  is  smooth  and  elastic.  Passing  the  index  along  it 
to  the  base,  we  feel  the  os  in  front  or  behind,  according  to  the  lip 
from  which  it  hangs ;  the  other  lip  is  usually  thinned  and  partially 
effaced.  This  circumstance  has  caused  the  error  of  supposing  the 
uterus  everted  or  that  the  tumor  came  from  the  interior  of  the  organ. 


238  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

Attentive  examination  of  both  lips  by  touch,  of  the  cavity  by  the 
sound,  and  of  the  position  of  the  organ  by  bimanual  palpation  will 
furnish  the  needed  corrections.  A  fibroma  of  the  external  os  may 
itself  be  pedicled,  and  the  fact  should  not  be  forgotten.  Finally, 
when  they  grow  at  the  level  of  the  vaginal  insertion  they  may  split 
the  recto-vaginal  septum  and  then  simulate  a  tumor  of  that  situation 23 
or  they  may  develop  toward  the  uterine  cavity.24 

B.  Submucous  Fibroma. — The  hemorrhages  and  the  increase  in 
the  size  of  the  uterine  cavity  are  here  especially  marked,  and  the  pres- 
ence of  the  tumor  is  readily  ascertained.  For  this  purpose,  touch 
should  be  practised  during  the  bleeding,  since  at  that  time  the  uterus 
is  softened  and  the  os  patulous.  If  necessary,  we  may  increase  the 
cervical  dilatation  by  the  means  already  described,  and  confirm  the 
diagnosis  by  intra-uterine  touch.  On  the  level  face  of  the  uterus 
there  is  then  to  be  felt  a  tumor  which  projects  into  the  cavity  and 
reduces  it  to  a  mere  linear  cleft,  laterally  distorted.  The  surface  of 
the  tumor  is  covered  by  hypertrophied  mucous  membrane,  which  is 
smooth  and  downy.  There  is  no  pedicle,  but  a  large  base  of  attach- 
ment, which  excludes  the  idea  of  a  polyp. 

Externally  the  uterus  has  a  globular  form  which  would  resemble 
that  of  the  first  months  of  pregnancy,  were  not  hemorrhages  excep- 
tional at  that  time. 

When  the  surface  of  the  tumor  has  become  gangrenous,  the  possi- 
bility of  a  mistaken  diagnosis  is  much  increased;  the  sanious  dis- 
charge, the  irregular  and  putrid  surface,  and  the  patient's  cachexia 
make  us  think  of  malignant  tumor,  or  of  cancer  of  the  body  of  the 
uterus. 

C.  Pedicled  or  Polypoid  Fibroma  of  the  Body. — We  can  divide 
the  evolution  of  a  polyp  into  three  stages,  ancl  each  one  of  these  cor- 
responds to  a  variety  of  fibroma.  In  the  first,  the  pedicled  fibroma  is 
still  far  from  the  uterine  cavity,  which  is  often  very  much  dilated ; 
that  is,  it  is  intra-uterine.  In  the  second  period  there  is  a  tendency 
to  pass  beyond  the  cervix,  after  dilating  it,  which  is  far  more  marked 
at  the  moment  of  the  monthly  discharge  and  disappears  between- 
while;  this  is  the  variety  with  intermittent  symptoms.  Finally,  in  the 
third  period  of  their  evolution,  these  polypi  protrude  completely  from 
the  uterus,  have  become  intra-vaginal,  and  may  take  on  an  enormous 
size,25  thus  forming  a  new  variety  from  the  point  of  view  of  the  symp- 
toms and  possible  operation. 

These  intra-uterine  polypi  may  be  distinguished  from  sessile  sub- 


DIAGNOSIS    OF   UTERINE   FIBROMATA.  289 

mucous  tumors  by  direct  examination  after  dilatation  of  the  cervix, 
the  presence  of  the  pedicle  being  characteristic. 

A  polyp  with  intermittent  symptoms,  occurring  at  the  menstrual 
periods,  may  pass  unrecognized  unless  we  see  the  patient  at  the  fa- 
vorable time  and  here  again  the  cervix  will  require  to  be  dilated, 
both  for  diagnosis  and  to  permit  removal. 

An  intra-vaginal  polyp  of  the  vagina,  coming  from  the  body  of  the 
organ,  would  seldom  be  confounded  with  a  sessile  or  pedicled  fibroma 
of  the  cervix;  touch  alone  should  reveal  its  relations.  We  might 
think  of  an  inverted  uterus,  especially  if  the  organ  itself  contained  a 
fibroma ;  and  this  error  is  very  easy  to  make,  as  is  shown  by  the  fact 
that  more  than  one  distinguished  surgeon  has  committed  it.  This  in- 
version may  be  unrecognized  in  two  conditions — if  there  is  a  compli- 
cating polyp  or  submucous  tumor  which  alone  attracts  attention;26 
and  when  it  is  the  only  alteration,  and  the  constriction  at  the  level  of 
the  internal  os  makes  the  upper  part  of  the  everted  organ  seem  like  a 
pedicle.27  The  operator  may  especially  note,  as  an  aid  in  guarding 
against  mistake,  the  extreme  sensitiveness  of  a  tumor  formed  by  the 
uterus,  though  this  symptom  is  very  inconstant.  But  the  sound  and 
rectal  touch,  combined  with  vesical  catheterism  and  bimanual  palpa- 
tion under  anaesthesia,  will  make  it  evident  that  the  uterus  is  not  in 
its  usual  place — that  we  have  to  do  with  a  case  of  uterine  prolapse. 

This  examination  is  at  all  times  difficult  with  polypi  which  are  of 
great  size,  for  they  fill  the  vagina  and  even  project  from  the  vulva, 
causing  a  displacement  of  the  uterus.  They  may  also  form  adhe- 
sions with  the  vaginal  walls,  provoke  ulcerations,  or  themselves 
slough  in  places ;  and,  more  than  that,  by  retention  of  decomposing 
fluids  above  them  in  the  occluded  vagina,  they  may  cause  the  absorp- 
tion of  these  putrid  products,  and  thus  seriously  disturb  the  gen- 
eral condition.  Though  the  statements  of  the  patient  and  the  local 
signs  might  lead  us  to  suspect  cancer,  a  careful  examination  will 
quickly  correct  the  error. 

III.  Fibroma  with  an  Abdominal  Evolution. 

A.  Subperitoneal:  Pedicled. — The  uterus  is  here  entirely  distinct 
from  the  tumor,  whose  movements  cannot  be  transmitted  to  the  finger 
placed  in  the  vagina  (Fig.  133).  The  cervix  is  generally  raised;  there 
is  usually  no  metrorrhagia;  and  the  cavity  of  the  uterus  is  not  en- 
larged.      Ovarian  cysts  are  the  most  difficult  things  from  which  to 


240  CLINICAL   AND    OPERATIVE   GYNECOLOGY. 

differentiate  these  fibromata.  The  fluctuation  in  the  cyst  would  be 
pathognomic,  but  it  might  be  confounded  with  the  softness  of  an 
cedematous  fibroma ;  and  if  the  cyst  were  small  and  tense  or  multiloc- 
ular,  with  small  areolar  cavities,  it  would  be  very  hard  to  appreciate. 
Examination  under  anaesthesia  would  then  be  necessary  to  remove  all 
doubt.  In  the  case  of  fibro-cystic  tumor  the  fluctuant  parts  alternate 
with  harder  portions. 

Another  point  for  consideration  is  that  the  fibroma  develops  very 
slowly  and  the  ovarian  cyst  rapidly.  As  Thornton  has  remarked, 
"there  are  certain  pedicled  fibromata  which  run  so  rapid  a  course 
that  confusion  is  easy,  as  they  also  react  but  little  upon  the  uterus ; 
and  thus  in  every  ovariotomy  we  should  be  prepared  to  do  a  hyster- 
ectomy." 2S 

Exploratory  puncture,  which  has  been  abused  in  former  years, 
should  be  completely  given  up;  it  may  cause  serious  accidents,  as 
discharge  of  the  cyst  within  the  abdomen,  internal  hemorrhage,  throm- 
bosis or  embolism  in  case  of  a  fibroma,  or  even  more  or  less  extended 
peritonitis.  Harsha 29  observed,  in  the  case  of  a  fibro-cystic  tumor,  that 
he  could  clearly  perceive  contractions  in  the  muscular  wall,  and  pro- 
posed to  anaesthetize  the  patient  at  the  menstrual  period — a  time  most 
propitious  for  the  examination — and  verify  the  existence  of  contrac- 
tions in  the  tumor  by  percussion. 

H.  Jones 30  has  described  an  exceptional  condition  of  the  gravid 
uterus  which  simulates  pedicled  fibroma.  In  four  observations  which 
form  the  basis  of  his  paper,  the  uterus  formed  a  hard,  round  tumor, 
movable,  and  of  the  size  of  the  fist,  between  the  symphysis  and  the 
umbilicus,  and  appeared  to  be  a  mass  connected  by  a  long  pedicle  to 
some  pelvic  organ.  Pressure  upon  the  tumor  moved  the  cervix  but 
little,  there  was  no  fluctuation,  and  the  sound  (before  the  pregnancy 
was  recognized)  gave  a  depth  of  the  uterine  cavity  of  12  cm.  The 
author  attributed  this  peculiar  state  of  the  organ  to  the  absence  of 
liquor  amnii;  the  fundus,  the  point  where  the  ovum  is  commonly 
attached,  would  then  become  globular,  while  the  lower  segment  would 
remain  lax;  hence  there  would  be  a  false  sensation  of  a  pedicle.  It  is 
very  probable  that  the  case  occurred  in  a  woman  with  hypertrophy 
of  the  supra-vaginal  portion  of  the  cervix.  A  short  delay  is  all  that 
is  needed  to  make  the  matter  clear. 

Floating  kidneys  may  be  recognized  by  their  contour  and  the 
entire  absence  of  any  connection  with  the  uterus. 

The  large  cancerous  cakes  formed  in  peritoneal  carcinoma  by  the 


DIAGNOSIS    OF    UTERINE   FIBROMATA.  241 

degeneration  of  the  omentum  may  be  mistaken  for  fibroma  if  there 
are  adhesions  to  the  uterus;  but  the  sanguinolent  ascites,  the  shape 
and  situation  of  the  tumors,  the  cachexia,  and  other  symptoms,  with 
the  freedom  of  the  uterus  as  disclosed  by  the  sound  and  bimanual 
palpation,  are  sufficient  to  distinguish  the  two  diseases. 

B.  Subperitoneal  Fibroma,  Sessile  and  Free :  Not  in  the  Broad 
Ligament. — The  differential .  diagnosis  is  here  the  same  as  in  the  pre- 
ceding cases.  Occasionally  it  is  very  difficult  to  diagnose  pregnancy 
complicated  by  such  a  tumor,  for  even  exact  analysis  of  the  symptoms, 
with  careful  attention  to  those  characteristic  of  the  foetus,  may  be 
without  result  during  the  first  months. 

Fibroma  of  this  variety  may  be  discovered  by  its  solid  union  with 
the  uterus,  for  the  two  constitute  but  a  single  mass  on  bimanual  pal- 
pation. At  the  same  time  the  examination  reveals  how  much  the 
lower  portion  of  the  organ  is  involved;  for  if  the  tumor  has  developed 
above  the  insertion  of  the  adnexa  this  part  will  be  intact,  but  in  the 
contrary  condition  it  will  become  a  part  of  the  tumor's  circumference. 
The  mass  is  then  immobilized  by  the  walls  of  the  lower  pelvis,  and 
permits  no  lateral  movements;  but  on  bimanual  palpation  we  feel 
that  the  iliac  fossae  are  free,  which  distinguishes  it  from  the  next  form. 

C.  a.  Intra-Ligamentous  Fibroma — Abdominal  Variety. — Here 
the  development  of  the  tumor  is  altogether  lateral,  splitting  up  the 
layers  of  the  broad  ligaments,  and  ordinarily  the  tumor  lies  in  one  of  the 
iliac  fossae,  and  fills  it  up.  By  touch  and  palpation  we  can  determine 
its  connections  with  the  uterus,  and  we  find  usually  that  but  one  of 
the  lobes  of  the  tumor  is  actually  in  the  ligament,  the  other  being 
above  it;  but  that  which  gives  the  tumor  its  name  and  importance 
is  its  very  grave  nature  and  the  special  therapeutic  measures  re- 
quired. It  is  only  exceptional  that  there  is  any  doubt  as  to  the  ex- 
istence of  a  fibroma,  though  before  complete  examination  we  might 
suppose  that  there  was  present  a  tumor  of  the  iliac  bone. 

Parovarian  cysts  within  the  broad  ligament  may  be  recognized  by 
their  fluctuation. 

Encysted  tumors  of  the  tubes,  especially  hydro-  and  hsemato- 
salpinx,  may  be  difficult  of  diagnosis  from  their  adhesion  to  the  pos- 
terior surface  of  the  uterus  and  the  difficulty  of  appreciating  any 
fluctuation ;  but  here  the  patient's  history,  the  use  of  the  sound,  and 
the  determination  of  the  grossesse  fibreuse  are  valuable  diagnostic 
measures. 

C.  b.  Intra-Ligamentous  Fibroma — Pelvic  Variety. — The  chief 

16 


242  .       CLINICAL   AND    OPERATIVE   GYNECOLOGY. 

characteristic  of  this  variety  is  found  in  the  development  of  the  neo- 
plasm within  the  pelvic  floor  between  the  organs  attached  there,  and 
its  tendency  to  fill  up  all  spaces  between  them  and  raise  the  body  of 
the  uterus  into  the  abdomen  (Fig.  136,  B).  Clinically  we  have,  as  the 
result  of  this,  the  most  serious  compression  symptoms,  and  for  the 
operator  there  are  extreme  difficulties. 

The  starting-point  of  these  tumors  is  always  in  the  subserous  por- 
tion of  the  uterus ;  that  is,  the  supra- vaginal  part  of  the  cervix  ;  if  their 
attachment  is  anterior,  while  their  volume  is  still  very  small,  they  may 
cause  grave  disturbance  of  the  bladder,  dysuria,  and  retention  of  the 
urine ;  and  it  is  in  this  variety  also  that  we  observe  especially  the 
intense  pain  caused  by  pressure  on  the  nerves,  as  well  as  the  acci- 
dents of  intestinal  compression. 

Vaginal  and  rectal  touch,  combined  with  palpation,  determine  the 
close  connection  of  these  tumors  with  the  organs  of  the  pelvis;  the 
culs-de-sac  are  found  to  be  depressed  or  obliterated,  and  the  cervix 
may  have  wholly  retracted  to  form  part  of  the  tumor.  About  its 
orifice,  of  which  only  the  external  os  may  remain,  there  are  felt  hard 
nodular  masses  which  are  connected  Avith  the  uterus  and  which  pres- 
sure does  not  displace ;  it  is  in  the  latter  respect  especially  that  these 
tumors  differ  from  those  of  the  body  of  the  uterus,  which  invade  the 
pelvis  only  as  there  is  a  retroflexion  developed.  These  latter,  which 
become  pelvic  by  immigration,  may  produce  the  same  symptoms  from 
compression  and  give  the  same  sensations  to  the  examining  finger, 
but  they  are  not  tightly  bound  down  unless  there  are  adhesions  of  in- 
flammatory origin;  and  pressure  made  through  rectum  and  vagina 
upon  the  morbid  mass,  with  the  woman  in  the  genu-pectoral  position, 
will  change  the  tumor's  place  if  it  does  not  return  it  above  the  su- 
perior strait. 

Hematocele,  inflammatory  foci  about  the  uterus,  and  encysted 
collections  in  the  tubes  are  at  times  difficult  of  diagnosis,  and  have 
been  the  cause  of  numberless  errors ;  no  doubt  the  so-called  medical 
treatment  of  fibrous  tumors  owes  much  of  its  success  to  this  fact. 
Before  finishing  the  clinical  description,  I  may  mention  certain  symp- 
toms which  are  occasionally  observed. 

It  is  common  to  all  tumors  which  compress  the  great  vessels  to 
present  an  intermittent  murmur,  called  the  uterine  souffle  in  preg- 
nancy. It  has  little  diagnostic  worth.  If  it  is  absent  in  a  case  of 
ovarian  tumor,  we  may  then  be  sure  of  finding  fluctuation ;  with  solid 
tumors,  on  the  contrary,  it  is  present. 


PROGNOSIS    OF    UTERINE   FIBROMATA.  243 

With  telangiectatic  fibroma  there  is  often  a  distinct  area  over  one 
of  the  broad  ligaments  where  we  find  a  continuous  murmur  which 
resembles  that  of  an  arterio-venous  aneurism,  and,  like  it,  is  accom- 
panied by  a  thrill ;  I  have  observed  one  such  case. 

Ascites  is  uncommon  with  fibroma,  but  it  may  develop  when  the 
tumor  is  very  movable  or  when  it  has  undergone  a  degeneration  from 
torsion  of  its  pedicle;  in  cachectic  subjects,  also,  it  will  at  times  appear 
with  tumors  which  in  another  patient  would  certainly  not  have 
caused  it.  I  have  observed  it  in  these  conditions  in  a  pjatient  who 
suffered  from  mental  disease,  where  hysterectomy  was  successfully 
performed  and  ameliorated  the  mental  condition.  Hemorrhagic  ascites 
is  an  almost  constant  symptom  with  malignant  tumor,  and  its  presence 
warrants  a  very  guarded  diagnosis.  I  have  already  spoken  of  chylous 
ascites  as  a  great  rarity. 

Serous  cysts  of  the  broad  ligament  coexist  quite  frequently  with 
fibroma  of  abdominal  development,  and  are  more  than  merely  fortui- 
tous, since  the  exaggerated  nutrition  caused  by  the  tumor  favors  their 
development  in  the  vestiges  of  the  Wolffian  body  which  constitute 
the  parametrium.  Some  large  tumors  of  the  uterus  drag  the  organ 
downward  and  cause  a  genital  prolapse,  as  do  also  some  of  the  ova- 
rian tumors.  Inversion  of  the  uterus  may  be  found  with  polypi,  and, 
exceptionally,  with  subserous  fibroma. 

A  rare  accident,  of  which  I  have  seen  one  case  and  which  has  been 
made  the  subject  of  a  thesis  by  Dull,  of  which  Schroder 31  has  given 
an  analysis,  is  the  separation  of  the  linea  alba  and  consequent  even- 
tration with  the  formation  of  a  hernial  sac,  in  which  the  large  fibroma, 
usually  pedicled,  is  found  lodged.  In  my  case  the  patient  was  an 
old  woman  who  had  carried  this  singular  hernia  many  years.  Its  size 
was  larger  than  her  head,  there  was  so  small  a  ring  that  reduction 
was  impossible,  and  the  sac  was  thinned  and  rested  irpon  her  knees. 
In  a  case  mentioned  by  Dull  death  followed  mortification  of  the  sac. 

Course  and  Prognosis. — The  great  majority  of  these  cases  present 
nothing  during  life  beyond  a  few  vague  symptoms  which  are  often 
unrecognized.  But  there  are  others  which  cause  serious  disturbance 
throughout  the  entire  period  of  sexual  activity  until  the  menopause, 
when  most  of  these  tumors  atrophy  and  diminish  in  volume  by  indu- 
ration and  involution.  This  effect  is  at  times  hastened  by  a  preg- 
nancy, but  the  rule  is  not  absolute.  A  certain  number  of  these 
tumors  have  a  veritable  "  galloping "  course,  as  I  have  termed  it,32 
causing  death,  not  so  much  by  the  hemorrhage,  as  by  the  exaggerated 


2-44  CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 

development  of  the  morbid  mass  and  the  phenomena  of  compression 
and  denutrition  which  result  from  it;  of  this  number  are  fibro-cysts 
in  general  and  some  simple  fibro-myomas.  On  the  other  hand,  there 
are  certain  tumors  of  a  less  rapid  course  which  continue  to  grow  in- 
definitely after  the  critical  age;33  but  most  frequently  there  is  a  dis- 
tinct retardation  at  that  epoch.34 

The  natural  evolution  of  a  fibroma  tends  toward  its  expulsion  from 
the  uterine  walls,  either  externally  or  into  the  peritoneal  cavity,  and 
this  effort  is  shown  by  the  pedicles  which  are  produced  in  these  two 
directions.  Although  such  cases  are  rare,  still  at  times  we  observe 
the  accouchement  of  a  polyp  under  the  influence  of  strong  uterine  con- 
tractions with  rupture  of  the  pedicle ;  or  the  same  thing  may  occur 
from  the  weight  of  the  tumor  alone  and  the  thinning  of  the  pedicle.35 
In  these  conditions  an  effort  of  defecation  or  of  vomiting  suffices  to  ex- 
pel the  polyp.36  The  rupture  of  the  capsule  of  a  submucous  fibroma 
may  produce  its  spontaneous  enucleation,  preceded  by  a  period  of 
pains  and  hemorrhage,37  or  suddenly  after  some  effort 3S  (see  Plate  V.), 
or  while  under  examination;  it  has  sometimes  followed  labor  and  the 
consecutive  contraction  of  the  uterus.39 

An  analogous  process  to  that  which  causes  the  rupture  of  the 
pedicle  of  a  submucous  polyp  may  also  liberate  a  fibroma  which  is 
subserous  and  pedicled.40  The  tumor  then  remains  grafted  to  some 
point  where  it  has  formed  adhesions,  or  lies  free  in  the  peritoneum 
and  undergoes  a  kind  of  mummification. 

Another  and  more  serious  mode  of  spontaneous  extrusion  is  pro- 
duced by  the  mortification  of  the  tumor,  the  sphacelated  portions 
tending  to  escape  outwardly;  at  times  this  takes  place  toward  the 
uterine  cavity  and  all  may  go  well,  despite  the  danger  of  infection. 
Or  there  may  be  perforation  of  some  neighboring  organ,  as  the  blad- 
der,41 the  recto- vaginal  pouch,43  or  the  abdominal  wall ;  the  two  former 
almost  always  causing  death,  the  latter  sometimes  ending  in  re- 
covery.43 Finally,  the  tumor  may  undergo  absorption,  as  I  have  said 
above,  after  pregnancy,44  or  at  the  menopause ; 45  but  in  the  latter  case 
there  is  more  truly  an  induration  and  diminution  than  complete  dis- 
appearance. Although  fibromata  are  an  undoubted  cause  of  sterility, 
fecundation  may  take  place  and  pursue  its  normal  course. 

The  cause  of  death  may  be  the  gradual  exhaustion  produced  by 
the  profound  anaemia  which  follows  repeated  hemorrhages,  or  it  may 
occur  f~om  successive  attacks  of  chronic  peritonitis,  from  disease  of 
the  kidneys  and  uraemia,  or  from  cardiac   complication  and  heart- 


ETIOLOGY    OF   UTERINE   FIBROMATA.  245 

failure.  Rupture  of  a  cyst,  or  inflammation  and  gangrene  of  the 
tumor,  propagated  with  or  without  perforation  to  the  neighboring 
serous  membrane,  may  set  up  an  acute  peritonitis,  with  a  rapidly  fatal 
termination.  Or  gangrene  of  a  submucous  tumor  may  be  the  origin 
of  a  fatal  septicaemia.  Ghastly,  sudden  death  has  been  observed  after 
embolism,46  especially  in  the  case  of  fibro-cysts  of  telangiectatic 
nature ;  exploratory  puncture  seems  to  favor  the  production  of  thrombi 
in  the  large  venous  sinuses.  Almost  immediate  death  by  shock  has 
been  observed  after  intra-abdominal  rupture  of  a  nbro-cystic  tumor.47 
Etiology. — In  spite  of  the  patient  researches  which  have  been 
made  upon  this  subject,  we  still  know  nothing  positive  about  the 
exciting  causes  of  uterine  fibroma;48  we  can  only  give  certain  predis- 
posing conditions,  among  which  are  race  (the  negro  being  more  s  ab- 
ject to  such  tumors  than  the  white)  and  advanced  age;  in  the  white 
races  the  most  susceptible  age  is  from  thirty  to  forty  years.  Ster- 
ility is  not  so  much  a  cause  as  a  consequence.  All  the  local  exciting 
causes  which  have  been  advanced  are  without  proof.  On  the  other 
hand,  it  has  been  supposed  that  a  celibate  life  disposed  to  their  for- 
mation ;  but  Gusserow's  statistics  disprove  the  idea.  Fehling 49  has 
attributed  great  importance  to  incomplete  involution  after  labor  and 
abortion  where  a  sufficient  period  of  repose  was  not  enjoyed. 

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1.  Matthews  Duncan  :   Edinb.  Med.  Journal,  1867,  p.  634. 

2.  G.  G.  Kidd  :  Dublin  Med.  Journal,  1872. 

3.  Jude  Hue  :  Annales  de  Gynecologie,  iv.,  p.  239. 

4.  Gallard  :  Lecons  Clin,  but  les  Mai.  des  Femmes,  2d  ed.,  page  887. 

5.  Hardie  :   Edinburgh  Medical  Journal,  Jan.,  1873. 

6.  Budin  :  Archives  de  Tocologie,  ii.,  p.  60. 

7.  Robert  Barnes :  Traite  Clinique  des  Mai.  des  Femrnes,  French  ed.,  Paris, 
1876,  p.  646. 

8.  Holdhouse:  London  Path.  Transact.,  iii.,  p.  371.  Duchaussoy:  Cited  by 
Jude  Hue.  Ann.  de  Gyn.,  vol.  iv.,  p.  239.  Dolbeau  :  Gaz.  des  H6pit.,  November 
29th,  1879. 

9.  Murphy  :  London  Journal  of  Medicine,  October,  1849.  Cited  by  Gusserow  : 
Loco  citato,  p.  52. 

10.  S.  Pozzi :  Annales  de  Gyn6c,  July,  1884.  Consult  also  for  renal  complica- 
tions with  fibroids— Hanot :  Soc.  Anatomique,  February  28th,  1873.  Jude  Hue  : 
Loco  citato.  Milliot :  Sur  les  Complic.  des  Turn.  Fibr.  de  l'Ut.  These  de  Paris, 
1875.  Fourestie  :  Gaz.  M<§dicale  de  Paris,  1875,  Nos.  6  and  7.  See  and  Skene  :  Am. 
Jour,  of  Obstetr.,  June,  1886.  Salen  and  Wallis  :  Hygeia,  Bd.  xlix.,  No.  2,  1887, 
analyzed  in  Centr.  f.  Gyn.,  1887,  No.  25.  Porak  :  Soctete'  de  Gynec.  de  Paris,  Jan. 
13th,  1887.  Annales  de  Gynecologie,  February,  1887.  A.  T.  Cabot :  Boston  Medical 
and  Surgical  Journal,  June  2d,  1887. 

•     11.  Gallard  :   Loco  citato,  p.  888.     See  4. 
12.  See  Amer.  Jour.  Obst.v  June,  1886. 


246  CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 

13.  Salin  and  Wallis  :   Hygeia,  Bd.  xlix.,  p.  402.     Centr.  f.  G-yn.,  No.  25,  1887. 

14.  A.  T.  Cabot :  Boston  Med.  and  Surg.  Jour.,  .Tune  2d,  1887.  A  case  of  sup- 
purating pyelitis,  due  to  fibroma,  cured  by  abdominal  hysterectomy. 

15.  Porak  :  Annales  de  Gyn.,  Feb.,  1881.  A  case  of  albuminuria  and  dyspnoea, 
without  doubt  uraemic,  which  disappeared  after  operation  on  a  uterine  polyp 
which  probably  compressed  the  ureters. 

16.  Jaccoud  :  Gaz.  des  Hopit,,  No.  116,  1886. 

17.  Kasperzik  (pupil  of  Hegar)  :  Centr.  f.  Gryn.,  No.  21,  1881.  Rose  :  Deutsche 
Zeit.  f.  Chirurg.,  Bd.  xiii.,  Heft  1.  Sanger:  Centr.  f.  Gryn.,  1884,  No.  37,  and  Arch, 
f.  Gyn.,  Bd.  xxiii. 

18.  Hofmeier  :  Zur  Lehre  vom  Shock,  etc.  Zeitschr.  f.  Geb.  und  Gyn.,  Bd.  xi., 
Heft  2,  page  366. 

19.  H.  Fehling:  Wurtemberg  Med.  Correspblatt.,  Nos.  1  to  3,  1887. 

20.  A.  J.  Dower  :  New  York  Med.  Journal,  p.  505,  1884. 

21.  Bedford  Fenwick:  Brit.  Gyn.  Jour.,  vol.  ii.,  p.  72. 

22.  Sebileau  :  Loco  citato. 

23.  P.  Mtiller  :   Scanzoni's  Beitrage,  vol.  iv.,  page  65. 

24.  Schauta:  Wien.  med.  Woch.,  No.  33,  1882. 

25.  S.  Pozzi :  Etude  sur  une  Var.  de  Polyp.  Fibr.,  etc.  Revue  de  Chirurg., 
Feb.,  1885. 

26.  Tillaux  :  Bull,  de  la  Soc.  de  Chir.,  1875. 

27.  Gosselin  :   Clin,  de  l'H6p.  de  la  Charit.,  vol.  iii.  p.  103. 

28.  Knowsley  Thornton  :   Lancet,  July  31st,  1886. 

29.  W.  M.  Harsha:  Amer.  Jour.  Obst.,  xx.,  p.  32. 

30.  H.  Jones:   Edinb.  Med.  Jour.,  March,  1888,  p.  790. 

31.  Dull :  Erlangen  Thesis,  1872.  Analyzed  by  Schroder  in  Mai.  des  Org.  G6n., 
French  ed.,  page  244. 

32.  S.  Pozzi:   De  la  Val.  de  l'Hysterectomie,  etc.,  1875,  p.  20. 

33.  E.  Rose  :   Deutsche  Zeit.  f.  Chir.,  Bd.  xxv.,  Heft  4  and  5. 

34.  C.  Schorler  :  Zeit.  f.  Geb.  und  Gyn.,  Bd.  xi.,  p.  153. 

35.  Whitefort :  Glasgow  Med.  Jour.,  August,  1872. 

36.  Routh  :   British  Med.  Jour.,  1864.     Marchant :  Virch.  Arch.,  lxvii. 

37.  Berdinel :   Arch.  d.  Tocologie,  iii.,  p.  249. 

38.  Munde"  :   Ainer.  Jour.  Obst.,  June,  1886. 

39.  Anderson  observed  the  spontaneous  elimination  of  a  fibroma  of  the  size  of 
an  egg,  without  hemorrhage,  three  days  after  delivery.  Hygeia,  Stockholm, 
August,  1887. 

40.  Simpson  :  Obst.  Works,  vol.  i.,  p.  716.  Turner  :  Edinburgh  Med.  Journal, 
January,  1861. 

41.  Guyon  :  Des  Turn.  Fib.  de  l'Ut6rus,  1860,  p.  65. 

42.  Demarquay  :  Bull,  de  la  Soc.  de  Chir.,  June  22d,  1859.  Orthmann  :  Centr. 
f.  Gyn.,  1886,  p.  737. 

43.  Loir:  Mem.  de  la  Soc.  de  Chir.,  1851,  vol.  ii.  Dumesnil :  Gaz.  d.  Hopit., 
1869,  No.  6. 

44.  Gueniot :  Bull.  Gen.  d.  Therap.,  March  20th,  1872. 

45.  Boinet:  Gaz.  hebdom.,  1873,  No.  18. 

46.  R.  Dohrn  :  Zeit.  f.  Geb.  und  Gyn.,  Bd.  xi.,  p.  136,  cases  1  and  3.  E.  Rose : 
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49.  Fehling:  Wurtemberg  Med.  Correspblatt.,  No.  iii.,  1887. 


CHAPTER    X. 

MEDICAL  TREATMENT    OF   FIBROMA— SURGICAL   TREATMENT 
OF   FIBROMA   WITH   A  VAGINAL  EVOLUTION. 

The  treatment  of  fibroma  may  be  divided  into  medical  and  sur- 
gical. 

Medical  treatment  of  these  cases  is  often  only  the  treatment  of 
the  symptoms.  The  various  substances  which  have  been  advocated 
for  the  purpose  of  acting  directly  upon  the  tumor  itself,  either  to 
cause  contraction  of  the  nutritive  vessels  (as  ergot)  or  to  set  up  a  fatty 
degeneration  (as  arsenic  and  phosphorus),  appear  to  produce  a  good 
effect  by  far  other  means;  the  first  contracting  the  uterine  vessels  and 
thus  decreasing  the  hemorrhage,  the  second  relieving  the  general 
malnutrition.  As  specific  agents,  electricity,  to  which  certain  authors 
attribute  considerable  importance  in  the  absorption  of  fibrous  tumors, 
and  mineral  waters  charged  with  sodium  chloride,  of  which  the  action 
is  incontestable,  may  be  mentioned. 

Ergot  injections  have  been  practised  since  the  writings  of  Hilde- 

brandt,1  who  gave  his  name  to  the  method.     The  treatment  must  be 

.  used  persistently  for  months ;  for  which  purpose  the  following  formula 

may  be  employed, 

Ghn. 

R>  Ergotini,  5.        .        .        gr.  lxxv. 

Chloral  hydrat.,  1.        .        .        gr.  xv. 

Aquai  destill.,        .        .        .     100.         .  ad  §  iij. 

M. 

and  twelve  minims  injected  daily.  If  it  is  desired  to  preserve  the 
solution  for  a  long  time,  it  is  well  to  add,  besides  the  chloral,  which  is 
intended  to- accomplish  the  same  object,  a  few  drops  of  Van  Swieten's 
fluid.  A  wire  must  be  kept  in  the  needle  to  insure  its  being  permea- 
ble, and  it  must  be  passed  through  the  flame  of  an  alcohol-lamp  after 
each  injection  to  dry  it,  and  beforehand  to  sterilize  it,  so  that  abscess 
may  be  avoided.  The  injection  is  best  made  in  a  fleshy  part,  like  the 
deltoid  or  the  buttock,  the  needle  being  inserted  perpendicularly  from 
a  half  to  three-fourths  of  an  inch.     To  prevent  pain,  Bumm  advises 


248  CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 

that  tlie  solution  be  neutralized  with  soda  and  filtered.2  The  patient 
may  be  taught  to  give  herself  these  injections;  Winckel  speaks  of  a 
woman  who  had  thus  done  it  fifteen  hundred  times. 

In  spite  of  the  so-called  demonstrative  cases  which  have  been  pub- 
lished, the  effect  of  this  method  upon  the  development  of  fibrous 
tumors  is  still  ■  contested.  Schroder  asserts  that  he  has  seen  no 
diminution  in  the  size  of  the  tumor  after  four  hundred  injections, 
although  the  dose  employed  was  stronger  than  the  one  I  have  indi- 
cated; 3  but  he  has  noticed  that  the  tumor  remained  stationary,  though 
it  had  been  increasing  up  to  that  time.  Leopold  recommends  the 
method,  and  Byf ord, 4  in  America,  is  its  warm  partisan.  On  the  other 
hand,  many  others  declare  that  they  have  never  obtained  any  good 
effect  from  it.5 

In  the  use  of  this  treatment,  if  the  prescribed  dose  is  much  ex- 
ceeded it  may  produce  cramps  of  the  extremities,  vomiting  and  fever, 
or  even  suppuration  of  the  tumor.6 

One  of  the  good  effects  attributed  to  the  ergot  treatment  is  that  it 
favors  the  spontaneous  expulsion  of  the  fibroma ;  but  it  is  doubtful  if 
it  will  cause  the  formation  of  a  pedicle  in  a  tumor  which  is  sub- 
mucous, and  those  which  are  already  polypoid  require  more  than 
medical  treatment. 

Churchill  and  MacClintock  strongly  advise  the  administration  of 
tincture  of  caDnabis  indica  in  six-drop  doses,  given  three  times  a  day, 
to  arrest  the  hemorrhage.  Antipyrine  has  been  tried  with  the  same 
object.7 

A  new  drug,  which  I  have  used  with  good  results,  lately  introduced 
into  European  practice  from  America  by  Freund,  is  the  fluid  extract 
of  hydrastis  canadensis.  This  acts  as  a  haemostatic  by  contracting 
the  vessels,  while  its  bitter  taste  makes  it  a  good  stomachic ;  the  dose 
is  twenty-five  drops  three  or  four  times  a  day.  Schatz  praises  the 
drug  highly,8  claiming  to  have  seen  a  fibroma,  which  had  reached  the 
umbilicus,  return  to  the  pelvic  cavity  after  two  years'  use  of  hydrastis. 
Lack  of  success,  according  to  him,  may  be  due  to  the  difficulty  of 
procuring  a  pure  form  of  the  medicine. 

Bromide  of  potash,  given  in  small  doses  for  a  long  time,  has  been 
advocated  by  Simpson;  but  it  seems  to  act  only  as  a  sedative  against 
the  pain,  and  its  prolonged  use  may  impair  the  digestive  function, 
which  it  is  so  important  to  preserve. 

Arsenic,  advised  by  G-ueniot,  does  not  display  the  selective  action 
which  had  been  hoped  from  it,  but,  as  a  tonic,  may  be  of  benefit. 


MEDICAL   AND    SURGICAL   TREATMENT    OF    FIBROMA.  249 

Baths  of  mineral  waters  containing  sodium  chloride  have  an  un- 
doubted beneficial  action  on  fibrous  tumors,  doing  more  than  simply 
improving  the  general  condition,  and  the  cases  where  I  have  obtained 
good  results  from  them  are  very  numerous.  Many  of  these  bitter 
waters  contain  alkaline  bromides  and  iodides  which  impart  to  them 
a  peculiar  sedative  action,  those  of  Salies-de-Bearn,  for  instance,  con- 
taining ten  grammes  of  bromide  of  sodium  to  the  quart.  As  the 
result  of  Apostolfs  work,  who  has  followed  with  rare  patience  the 
way  opened  by  his  master  Tripier,9  electricity  has  recently  been 
much  employed,  especially  in  America  and  England. 

The  application  of  electrolysis  to  fibromata  was  made  in  1871  by 
Cutter,10  in  Ameria,  and  in  1876  by  Ciniselli  and  his  pupil  Omboni 
in  Italy. 

As  is  well  known,  the  effect  of  a  strong  current  of  electricity  is  to 
produce  chemical  decomposition  of  the  tissues,  the  positive  electrode 
attracting  the  acid  elements  and  the  negative  the  basic:  if  then  we 
put  the  positive  (acid)  pole  in  contact  with  the  tissues,  either  on  the 
surface  of  the  mucous  membrane  or  in  the  depth  of  the  tumor,  we 
produce  an  eschar  similar  to  that  which  follows  the  application  of 
acids,  ending  in  a  cicatrix  which  is  fibrous  and  retractile.  If  the  con- 
tact has  been  made  with  the  negative  pole,  the  result  is  a  soft  non- 
retractile  eschar,  like  that  caused  by  potassium  hydrate.  This  exces- 
sive chemical  action  can  be  prevented  at  one  or  the  other  pole  by 
largely  increasing  its  area  and  covering  it  with  some  good  conduct- 
ing substance  (clay,  gelosin,  gelatin,  wet  cotton  or  chamois  leather, 
etc.),  which  spreads  it  over  so  large  a  surface  that  its  action  is  not  felt. 

The  first  who  employed  electricity  used  feeble  currents  which 
had  a  catalytic  effect  without  actual  destruction  of  the  tissues,  and 
many  authors  still  hold  to  this  method  as  least  dangerous.11  But  the 
great  majority  follow  the  example  of  Apostoli 12  and  Engelmann ls  (of 
St.  Louis),  employing  currents  of  high  intensity  from  a  battery  of 
Leclanche  cells.  Apostoli,  in  1884,  did  not  use  more  than  100  milliam- 
peres ;  he  now  reaches  250  at  times.  The  strength  of  the  current  is 
measured  by  a  galvanometer.  (The  "  ampere  "  is  the  current  devel- 
oped by  an  electromotive  force  of  one  "volt"  in  a  circuit  where  the 
total  resistance  is  one  "  ohm."  The  "  volt "  is  an  electromotive  force 
which  differs  but  little  from  that  of  one  "Daniel!"  cell;  the  "ohm" 
is  the  resistance  of  a  column  of  mercury  1  mm.  square,  5  cm.  long.) 
His  technique  is  as  follows : 

One  of  the  poles  is  applied  to  the  abdomen  by  means  of  a  large 


250  CLINICAL   AND    OPERATIVE   GYNECOLOGY. 

moist  clay  electrode  or  other  appropriate  medium,  and  the  other  pole 
is  introduced  into  the  uterine  cavity  in  the  form  of  a  platinum  or 
carbon  sound,  which  is  insulated  with  celluloid  or  rubber  over  the  part 
which  does  not  enter  the  uterine  cavity.  The  electrode  is  pushed  into 
the  substance  of  the  organ  "after  preliminary  puncture  where  we  de- 
sire to  hasten  the  denutrition  of  the  neoplasm,  or  where  the  cervix  is 
impermeable  or  inaccessible."  Thus  an  intra-uterine  eschar  is  pro- 
duced, the  positive  pole  being  used  when  the  tumor  is  hemorrhagic, 
the  negative  in  the  opposite  case. 

Apostoli  asserts  that  "  if  well  applied  and  continued  long  enough 
(from  three  to  nine  months),  this  method  is  very  successful,  leading 
in  95/o  of  the  cases  to  the  reduction  of  the  tumor  from  one-fifth  to 
one-third  of  its  former  size,  and  sometimes  to  one-half  and  producing 
rapid  and  lasting  control  of  the  hemorrhage,  and  disappearance  of 
compression  symptoms." 

Engelmann  describes  a  similar  technique,  with  the  employment  of 
50  to  250  milliamperes  during  three  to  six  minutes ;  exceptionally  with 
double  puncture  of  the  tumor  through  the  vagina. 

The  mode  of  action  seems  to  be  a  double  one.  In  the  first  place 
the  mucous  membrane  is  cauterized,  producing,  as  Apostoli  expresses 
it,  an  actual  electric  curettage;  and,  as  well  known,  the  curette  will 
often  control  hemorrhage  by  destroying  the  diseased  mucosa:  both 
curette  and  electricity  may  thus  cause  a  superficial  mortification  of  a 
submucous  fibroma.  Brose14  especially  insists  upon  this  mode  of 
action  for  electricity,  and  Mcaise 15  agrees  with  him  in  considering  the 
destruction  of  the  mucous  membrane  as  the  chief  benefit  derived  from 
it;  this  destruction  is  never  more  than  an  incomplete  one,  in  a  straight 
line  corresponding  to  the  sound  in  the  uterus.  It  should  not  be  com- 
pared with  that  obtained  by  the  curette,  which  works  effectively  in  all 
directions,  penetrating  air  the  corners.  Danion,16  in  his  experiments 
with  animals,  demonstrated  that,  with  a  sound  introduced  into  the 
uterine  cornu  of  a  rabbit,  the  current  used  by  Apostoli  caused  but 
very  slight  cauterization. 

Still  another  mode  of  action  is  claimed  by  all  partisans  of  the 
method,  whether  they  use  feeble  or  strong  currents,  namely,  the  so- 
called  "interpolar"  action.  Unfortunately  this  is  pure  theory;  is  it 
a  chemical  change  in  the  living  elements  of  the  tumor,  or  a  vaso-motor 
effect  with  electro-tonic  action  on  the  muscular  fibres?  Danion  has 
even  spoken  of  galvanic  massage,  insisting  that  the  current  be  reversed 
for  the  purpose.     All  these  ideas  are  hypothetical  and  rest  upon  im- 


MEDICAL   AND    SURGICAL   TREATMENT   OF   FIBROMA. 


251 


agination  only.17    The  method  is  not  altogether  safe,  for  several  fatal 
cases  have  been  already  recorded.18 

Far  more  dangerous  yet  is  the  method  of  Cutter,  who  employs  a 
battery  of  great  strength  and  pierces-  the  tumor  in  two  places,  either 
through  vagina,  rectum,  or  abdominal  wall:  he  has  had  four  deaths  in 


^ 


l 


I 


Fig.  140. — Apostolus  Uterine  Electrode.  1,  Natural  size  of  the  instrument;  A,  ordinary  hystero- 
meter;  B,  trocar  for  puncture;  F,  notch  marking  average  depth  of  uterus.  2  and  3,  Entire  instrument, 
reduced  to  %  size,  in  C,  celluloid  handle,  to  protect  the  vagina;  E,  electrode;  1),  thumb  screw,  to  regulate 
length  of  exposed  sound.  4,  Carbon  electrode  for  galvano-chemical  cautery ;  ya  size.  Apostoli  now  replaces 
the  platinum  trocar  by  one  of  gold  or  steel,  which  have  the  advantage  of  being  more  readily  sharpened. 


his  first  50  cases.  His  results  are  as  follows :  arrest  of  the  tumor,  25 
cases ;  tumor  not  arrested,  7  cases ;  improvement,  3  cases ;  cure,  11  cases. 
Cutter,  in  seeking  the  electrolytic  destruction  of  the  tumor,  follows 
other  theoretical  views  than  those  of  Apostoli,  though  the  latter  seems 
to  have  made  certain  attempts  in  the  same  direction,  when  in  excep- 
tional cases  he  buried  the  electrode  deexDly  in  the  centre  of  the  tumor. 


252 


CLINICAL   AND   OPEKATIVE   GYNAECOLOGY. 


One  of  the  inconveniences  of  this  method  is  that  it  gives  rise  to  pro- 
tracted suppuration.19 

Keacting  against  these  violent  measures,  Danion  and  Champion- 
niere20  advise  the  employment  of  feeble  currents  of  from  45  to  65 
milliamperes,  or  very  rarely  up  to  90,  claiming  that  these  weaker 
currents  are  quite  as  satisfactory  as  the  stronger.  Danion  attaches 
much  importance  to  frequent  reversal  of  the  current.     He  introduces 


^Kariwinsk.1. 


Fig.  141.— 1,  Tripier's  Unipolar  Uterine  Electrode;  2,  Apostolus  Bipolar  Uterine  Electrode. 

the  electrode  into  the  cervix,  but  claims  that  he  can  obtain  the  same 
effects  by  placing  it  in  the  vagina  if  he  takes  the  necessary  precau- 
tions.21 

It  is  very  difficult,  even  now,  to  pass  judgment  upon  the  value  of 
electrolysis  as  applied  to  uterine  fibromata.  Diverse  opinions  are 
held  in  New  York,22  in  London,23  in  Berlin,24  and  in  France.  Doleris,25 
who  has  employed  the  method  in  a  series  of  twenty  cases,  thinks 
that  he  is  often  the  victim  of  an  illusion,  mistaking  for  a  diminution 


MEDICAL   AND    SURGICAL   TREATMENT   OF   FIBROMA.  253 

in  the  size  of  the  tumor  what  is  really  only  its  subsiding  into  the  lesser 
pelvic  cavity.  One  must  further  be  on  his  guard  not  to  mistake  for 
the  tumor  the  perimetritic  exudations  which  often  become  absorbed 
as  the  result  of  the  rest  and  good  care.  The  value  of  this  treatment 
has  been  overestimated  as  regards  the  diminution  in  the  size  of  the 
tumor,  for  when  this  effect  is  produced  it  is  only  temporary  and  ceases 
when  the  electricity  is  discontinued,26  but  the  majority  recognize 
that  it  does  lessen  the  hemorrhages  and  the  pain  and  improve  the 
general  condition. 

Without  accepting  the  exaggerations  of  Keith,  who  has  declared  it 
criminal  to  practise  hysterectomy  unless  electricity  had  been  first  em- 
ployed, we  should  remember  that  in  it  we  have  a  therapeutic  resource 
which  should  not  be  neglected  in  those  cases  where  operation  cannot 
promise  a  radical  cure. 

I  will  only  mention  the  use  of  the  interrupted  constant  current,  of 
which  Aime  Martin  and  Cheron  have  spoken  warmly ;  its  employment 
is  no  more  useful  or  general  than  is  the  use  of  faradization. 

[While  ultra-enthusiasm  and  too  great  expectations  have  undoubt- 
edly led  to  failure  or  disappointment  in  the  use  of  electricity,  as  I 
have  stated  in  Sajou's  "  Annual "  for  1890,  from  which  the  following 
is  taken,  there  can  be  no  question  of  its  importance  as  a  palliative 
therapeutic  agent.  When  carefully  employed,  the  treatment  is  gen- 
erally considered  to  be  free  from  any  danger  to  life,  unless  electro- 
puncture  be  the  method.  Most  of  the  unsatisfactory  results  have 
been  in  the  case  of  tumors  which  have  proved  cystic — a  condition 
which  absolutely  contra-indicates  the  use  of  electricity — or  in  cases 
where  the  proper  precautions  in  regard  to  cleanliness  or  asepsis  were 
not  employed. 

The  consensus  of  opinion  is  practically  that  expressed  by  Deletang, 
who  states  that  the  immediate  effects  of  electrolysis  consist  in  (1) 
contraction  of  the  uterus  and  its  tumors ;  (2)  a  congestion  of  the  ad- 
jacent tissues,  which  continues  for  several  hours  and  is  attended  with 
colic ;  (3)  a  subsidence  of  pre-existing  hemorrhages.  The  consecutive 
effects  are:  1.  Slight  hemorrhage.  2.  Pain,  with  functional  disturb- 
ance. These  phenomena  have  no  relation  to  the  tumor,  belonging 
rather  to  the  inflammatory  zone  surrounding  it,  and  quickly  pass 
away.  3.  The  tumor  diminishes,  the  morbid  symptoms  disappear, 
and  the  general  nutrition  improves.  There  is  sometimes  a  temporary 
aggravation  of  the  symptoms  at  the  commencement  of  the  treatment, 
depending  on  the  congestion  mentioned  above. 


254  CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 

Some  knowledge  of  electro-physics,  carefulness  in  manipulation, 
and  exactness  in  dose  are  necessary  to  the  effective  employment  of 
galvanism,  together  with  a  proper  selection  of  the  cases  and  accurate 
knowledge  of  the  tumors  to  be  treated.  Ordinarily  no  fibroid 
should  be  attacked  by  galvano-puncture  when  it  is  possible  to  reach 
it  through  the  uterine  canal.  When  the  tumor  can  only  be  reached 
by  puncture,  this  should  be  either  through  the  cervix  or  the  vaginal 
wall,  using  particular  care  to  determine  beforehand  the  position  of  the 
bladder,  so  that  it  may  be  avoided.  No  tumor  in  which  there  is  a 
suspicion  of  cystic  regeneration  should  be  treated  by  electrolysis. 
The  current  must  be  localized  and  its  effects  confined  as  closely  as 
possible  to  the  neoplasm.  One  pole  must  serve  as  the  active  agent  for 
the  application  of  the  electricity,  and  upon  this  its  entire  effect  is. 
concentrated.  This  is  termed  the  active  pole.  The  current  at  the 
opposite  pole  is  to  be  dispersed  over  as  large  a  surface  as  possible,  so 
that  its  effects  will  be  least  perceptible.  The  poles  should  be  placed 
on  opposite  sides  of  the  diseased  part,  and  as  near  to  it  as  possible, 
the  indifferent  pole  being  placed  on  the  largest  and  least  sensitive 
surface.  The  current  should  be  of  sufficient  strength  to  accomplish 
"the  object  desired  in  the  shortest  possible  time  without  detriment  to 
the  patient.  This  strength  will  usually  be  from  80  to  250  milliam- 
peres.  The  first  instrument  required  is  a  battery  of  sufficient  constancy 
and  strength.  One  which  has  been  found  most  serviceable  is  com- 
posed of  fifty  or  sixty  improved  Law  or  Leclanche  cells.  These  can 
"be  stored  in  any  closet,  or  even  in  the  cellar,  connected  in  series  with 
wires  leading  to  any  convenient  spot  in  the  office.  Here  we  need  a 
rheostat  for  the  purpose  of  controlling  the  current  strength,  and  an 
amperemeter  for  measuring  the  amount  used.  In  addition  to  these, 
there  are  the  connecting  cords,  the  abdominal  and  the  internal  elec- 
trodes. The  abdominal  electrode  may  be  the  original  one  of  clay, 
originally  devised  by  Apostoli,  or  a  thin  plate  of  lead  or  tin  (Engel- 
mann),  as  large  as  can  be  used  upon  the  abdomen,  covered  with  a  thin 
layer  of  soft  clay,  held  in  place  by  gauze;  or  it  may  be  made  of  gauze 
covered  with  wet  canton  fiannel,  or  thin,  soft  buckskin,  held  in  place 
on  the  abdomen  by  a  quilted  sand-bag.  The  internal  electrode  is 
either  a  gold  or  platinum-plated  sound,  or  a  curved  rod  of  carbon,  or, 
for  electro-puncture,  a  strong  steel  needle,  insulated  to  within  one-half 
inch  (12.5  millimetres)  of  the  point. 

If  electro-puncture  is  to  be  employed,  or  the  patient  is  hyperses- 
thetic  or  nervous,  anaesthesia  will  be  necessary;  but,  ordinarily,  if 


MEDICAL   AXD   SURGICAL   TREATMENT    OF   FIBROMA.  255 

skilfully  and  carefully  used,  the  current  may  be  passed  without  an 
ansesthetic.  The  patient  is  to  be  put  upon  the  operating-table  or 
chair  in  the  dorsal  decubitus,  the  clothing  loosened  about  the  waist, 
the  corset  removed;  the  abdominal  electrode,  previously  soaked  in 
warm  water,  is  then  snugly  adapted  to  the  abdomen,  so  that  the  epi- 
dermal layers  of  the  skin  may  have  a  chance  to  become  thoroughly 
moistened,  the  current  then  passing  with  much  less  resistance  and 
consequently  less  pain.  Before  placing  this  electrode,  any  scratches, 
pimples,  or  excrescences  should  be  covered  with  bits  of  plaster  or 
oiled  silk,  as  otherwise  the  passage  of  the  current  will  cause  much 
pain  at  these  points.  Warm,  dry  towels  should  be  placed  over  and 
above  the  electrode  to  protect  other  portions  of  the  patient's  body,  as 
well  as  her  garments,  from  any  excess  of  moisture.  The  vagina 
should  now  be  cleansed  by  an  antiseptic  douche  and  the  uterine  elec- 
trode carefully  introduced ;  or,  if  galvano-puncture  is  to  be  employed, 
the  needle  is  introduced  to  the  depth  of  from  1  inch  to  1|  inches  (25  to 
37  millimetres)  at  a  point  previously  determined.  Being  certain  that 
the  rheostat  is  at  its  greatest  point  of  resistance,  the  connecting  cords 
are  now  attached  to  the  electrodes  and  the  current  turned  on  very 
slowly  and  evenly,  so  that  in  the  course  of  a  minute  we  have  increased 
it  from  nothing  up  to  50  or  100  milliamperes  or  more.  The  first  sit- 
ting should  not  be  for  a  longer  time  than  six  minutes,  the  current 
remaining  at  its  strongest  for  half  of  this  time,  and  then  being  slowly 
reduced.  During  the  passage  of  the  current  the  operator  must  con- 
stantly observe  both  his  galvanometer  and  the  patient.  The  needle 
should  remain  perfectly  steady,  with  no  oscillations  which  would  in- 
dicate jar  or  shock.  The  operator  must  be  particularly  careful  to 
avoid  any  accident  which  might  produce  a  sudden  change  in  the  in- 
tensity of  the  current,  as  the  shocks  thus  produced  are  exceedingly 
trying.  At  the  end  of  the  sitting  the  vagina  should  be  again  douched 
and  the  patient  kept  in  bed  for  the  rest  of  the  day.  If  there  are  evi- 
dences of  pain  or  reaction,  and  in  susceptible  individuals,  it  is  well  to 
insist  on  rest  in  bed  for  several  days,  together  with  the  use  of  the  ice- 
bag  over  the  region  of  the  tumor.  Should  there  be  any  bleeding,  it 
may  be  necessary  to  tampon  the  vagina  with  styptic  cotton.  The 
necessity  for  this,  however,  is  rare.  We  must  always  warn  the  patient 
of  what  is  coming;  we  must  first  apply  the  moistened,  warm,  dispers- 
ing electrode  to  the  abdomen;  we  must  have  the  intra-pelvic  electrode 
aseptic,  and  introduce  it  with  the  greatest  possible  gentleness;  we 
must  thoroughly  insulate  all  but  the  active  portions  of  the  instru- 


256  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

ment,  avoiding  metallic  contact  with  vagina,  vulva,  or  speculum,  and 
never  establish  the  current  until  intra-pelvic  disturbance  has  ceased; 
always  increase  the  current  very  gradually,  bearing  in  mind  that  the 
intra-uterine  or  intra-pelvic  pole  must  never  cause  pain.  All  shock 
must  be  avoided,  the  connections  made  before  the  current  is  estab- 
lished, and  not  broken  until  it  is  entirely  turned  off.] 

Treatment  of  Tumors  Incarcerated  in  the  Pelvis. — Certain  fibrous 
tumors,  either  developing  in  the  lesser  pelvis  or  retroflexed  into  it, 
may  cause  serious  compression  of  the  rectum,  bladder,  or  nerves, 
even  producing  ileus,  uraemia,  or  paraplegia.  At  times  all  these 
symiotoms  may  be  relieved  by  replacing  the  tumor  above  the  pro- 
montory. The  patient  is  put  in  Sims'  position,  or,  better,  in  the 
genu-pectoral,  and  the  tumor  is  elevated  by  pressure  from  the  vagina 
or  the  rectum;  if  there  is  much  muscular  contraction,  chloroform 
should  be  used.  This  procedure  may  be  adopted  also  in  cases  of 
pregnancy  complicated  with  fibroma  at  the  time  of  parturition. 

Minor  Haemostatic  Operations. — Before  the  description  of  the 
major  operations  for  the  relief  of  fibroma,  a  few  words  may  be  said 
about  the  more  simple  surgical  measures  which  are  employed  against 
the  often  very  serious  hemorrhage. 

Curettage  and  Intra-uterine  Injection. — This  measure  has  fre- 
quently been  adopted,  often,  without  doubt,  from  an  erroneous  diag- 
nosis of  hemorrhagic  endometritis.  Recent  researches  demonstrate 
that  it  is  nevertheless  the  correct  thing  to  do.  It  may  be  successful 
when  the  uterine  cavity  is  not  much  deformed  and  the  curette  can  be 
employed  efficaciously.27  The  injection  of  perchloride  of  iron  with 
Braun's  syringe,  and  copious  washing  afterward  with  the  double- 
current  catheter,  as  described  under  the  head  of  metritis,  may  then 
follow.  Such  injections  must  always  be  made  with  the  greatest  care, 
remembering  that  the  tubes  may  be  markedly  dilated  and  permeable. 

Dilatation  of  the  Cervix. — This  operation,  advised  by  Baker 
Brown,  MacClintock,  and  Nelaton,  has  been  recently  advocated  by 
Kaltenbach,28  who  uses  Hegar's  bougies,  from  16  to  18  mm.,  and  in 
certain  cases  has  obtained  remarkable  success.  He  attributes  great 
importance  to  the  narrowness  of  the  cervical  canal  in  the  causation 
of  both  pain  and  bleeding  with  myomata,  and  especially  recommends 
this  palliative  measure  in  women  with  a  small  tumor  who  are  near  the 
menopause  or  when  it  is  desirable  to  gain  time.  I  have  seen  good 
results  from  it. 

Bilateral  Section  of  the  Cervix. — This  operation  was  done  first  by 


MEDICAL  AND   SURGICAL   TREATMENT   OF   FIBROMA.  257 

Nelaton,  then  by  Baker  Brown,  and  recently 29  has  been  recommended 
anew ;  but  as  the  incision  must  be  carried  down  to  the  chief  branches 
of  the  uterine  artery,  it  amounts  to  nothing  more  than  ligation  of 
these  vessels.  It  is  of  benefit  only  when  the  neoplasm  occupies  the 
lower  segment  of  the  uterus,  and  is  thus  of  restricted  application. 

Intro-uterine  Scarification. — In  cases  of  obstinate  bleeding  de- 
pending upon  an  intra-uterine  fibroma,  Martin 20  claims  to  have  had 
good  results  from  a  measure  formerly  employed  by  Simpson,  namely, 
the  division  of  the  capsule  by  scarification  upon  the  projecting  part 
of  the  submucous  tumor,  the  severed  vessels  undergoing  retraction. 

Surgical  Treatment  of  Fibrous  Tumors. 

The  operations  applicable  to  fibromata  differ  according  as  the 
tumors  are  accessible  by  the  natural  passages  or  only  by  laparatomy. 
The  progress  of  operative  gynecology  permits  us  to-day  to  avoid  in 
most  cases  the  division  of  the  abdominal  walls. 

I  shall  treat  in  this  chapter  only  of  those  tumors  which  by  their 
evolution  toward  the  vagina  may  be  reached  by  that  passage. 

A.  Fibroma  of  the  Vaginal  Portion  of  tlie  Cervix. — In  the  cer- 
vix, owing  to  the  small  size  of  the  part,  we  do  not  distinguish  between 
submucous  and  interstitial  tumors.  They  are  ordinarily  not  difficult 
to  detach  from  the  surrounding  tissues,  and  we  may  then,  as  Lisfranc 31 
and  all  other  surgeons  have  done,  attempt  to  enucleate  them  by  the 
aid  of  finger  and  spatula  after  removal  of  their  lower  portion  and 
a  section  of  the  tissue,  or  making  a  conical  excision,  in  order  to  facili- 
tate the  manoeuvre. 

It  is  always  useless  to  complicate  the  operation  by  the  employ- 
ment of  the  ecraseur  or  the  galvano-caustic  loop ;  the  latter  is  danger- 
ous to  the  surrounding  parts  and  of  too  delicate  an  action,  and 
should  be  used  only  in  exceptional  cases.  The  ecraseur,  which  many 
surgeons  still  advise  for  the  ablation  of  tumors  by  the  vagina,  has 
several  defects — it  may  break  on  tissues  of  great  resistance,  it  cuts 
very  slowly  and  causes  a  loss  of  time  during  which  the  uterus  may  be 
bleeding  above  the  tumor,  and  it  has  a  tendency  to  rise  upward  by  a 
climbing  motion  on  very  hard  tissues,  which  has  caused  the  per- 
itoneum to  be  opened.32  To  avoid  loss  of  blood,  the  best  way  is  to 
proceed  as  quickly  as  may  be  with  the  bistoury;  fibrous  tumors 
are  not  very  vascular,  and,  if  certain  vessels  bleed,  it  is  easy  to  arrest 
the  hemorrhage  by  means  of  forceps  or  the  thermo-cautery.     If  the 


258 


CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 


cervical  tumor,  as  in  one  of  Schauta's  cases,  is  prolonged  above  into 
the  uterus,  we  should  not  follow  it  too  far,  but  limit  the  operation  to 
the  removal  of  the  accessible  part,  leaving  the  base  in  position,  which 
without  doubt  will  be  pushed  downward  by  the  uterine  contractions, 
and  may  then  be  extirpated.  If  the  tumor  has  no  capsule,  we  may 
amputate  it  as  high  as  possible,  saving  two  lips,  which  should  then 
be  reunited.  When  there  is  a  clean  wound  after  enucleation,  we  may 
equalize  its  edges  and  suture  them ;  but  if  primary  union  seems  im- 
probable, it  is"  better  to  remove  the  debris  of  the  capsule  and  pack 
the  cavity  with  iodoform  gauze. 

B.  Pedicled  Fibroma  of  the  Body  or  Polyp. — When  the  tumor  is 
intra-uterine,  it  is  necessary  to  do  a  preliminary  operation  to  render 
it  accessible;  this  is  best  accomplished  by  the  bilateral  division  of  the 
cervix  with  strong  scissors  up  to  the  vaginal  insertion.     The  upper 


Fig.  142.—  Museux  Forceps. 


portion  of  the  canal  is  usually  dilated  by  the  tumor  itself ;  if  other- 
wise, the  part  is  softened  by  laminaria  tents,  and  then  dilated  by 
Hegars  bougies;  or  we  may  make  a  bilateral  incision  (pp.  112  to  118). 
The  ablation  of  the  polyp  is  ordinarily  very  simple.  The  patient  is 
placed  in  the  dorso-sacral  position;  the  vagina  is  dilated  with  a  spec- 
ulum or  retractors ;  and  the  polyp,  being  seized  with  toothed  forceps 
(Figs.  142  and  143),  is  drawn  downward  as  much  as  possible  while  the 
hand  above  the  pubes  examines  that  the  uterus  is  not  inverted.  Then 
the  pedicle  is  twisted  by  imparting  to  the  polyp  a  movement  of  rota- 
tion on  its  axis,  and  after  two  or  three  turns  a  pair  of  strong  scissors, 
curved  on  the  flat,  is  slid  up  to  the  attachment  of  the  pedicle,  which 
is  then  divided  by  small  cuts  while  the  torsion  continues;  this  has  the 
double  effect  of  aiding  the  extraction  of  the  tumor  and  lessening  the 
hemorrhage. 

The  usual  advice  is  to  cut  the  pedicle  as  high  as  possible ;  but  by 
a  lower  section  I  think  that  there  is  less  risk  of  secondary  hemor- 


MEDICAL   AND    SURGICAL   TREATMENT    OE   FIBROMA.  259 

rhage,  and  the  stump  retracts  within  the  cavity  of  the  uterus  and  is 
rapidly  obliterated. 

All  the  measures  devised  with  a  view  to  prevent  bleeding  should 
be  resolutely  abandoned;  they  have  resulted  in  more  victims  than 
cures.  Galvano-cautery,  ligature,  and  ecraseur  all  prolong  and  com- 
plicate an  operation  which,  to  be  safe,  should  be  rapid.  Even  Dupuy- 
tren  contended  against  the  chimerical  fear  of  hemorrhage,  and  ad- 
vised the  cutting  instrument ;  it  is  time  to  return  to  his  practice.  In 
the  very  rare  cases,  of  which  Trelat  has  cited  an  example,33  where  the 
pedicle  contains  large  vessels,  the  condition  may  be  recognized  by 
palpation,  and  before  operating  a  pressure  forceps  should  be  placed 
on  the  part  and  allowed  to  remain  for  several  hours.  If  there  is 
much  loss  of  blood,  hot  injections,  ergot,  and  tamponade  with  iodo- 
form gauze  will  easily  check  the  hemorrhage. 


Fig.  143.— Collin's  Tumor  Forceps. 

I  have  rjroposecl 34  the  name  "  enormous  polyps  "  for  those  which  fill 
the  vagina,  do  not  permit  the  finger  to  reach  the  pedicle  and  can- 
not be  easily  removed  through  the  vulva ;  these  peculiar  polyps  offer 
special  operative  indications.  The  pedicle  should  not  be  treated  un- 
til the  volume  of  the  tumor  has  been  diminished — a  result  easily  ob- 
tained by  combining  certain  measures  which  have  been  advised  at  dif- 
erent  times.  Simon's 35  method  consists  in  making  a  series  of  trans- 
verse deep  incisions  one  above  another,  until  the  pedicle  is  reached; 
Hegar36  attains  the  same  object  by  a  series  of  spiral  incisions 
on  the  capsule  of  the  tumor,  which  is  always  the  most  resistant  part. 
Lastly,  tbe  fragmentary  removal  of  the  polyp  by  a  number  of  conoidal 
excisions  seems  to  me  the  best  method.37  It  is  better  to  attack  the 
tumor  at  the  fourchette  and  make  our  incisions  at  that  level,  as  ad- 
vised by  Dupuytren.33  When  the  volume  of  the  tumor  has  been  suf- 
ficiently diminished,  it  is  seized  between  the  branches  of  wide-jawed 
forceps  (Fig.  144) ;  this  compression  reduces  its  size  still  more ;  and  by 


260 


CLINICAL  AND   OPERATIVE   GYNECOLOGY. 


small  incisions  with  the  scissors,  and  torsion,  the  section  of  the  pedicle 
is  completed. 

When  the  patient  is  cachectic  or  enfeebled,  it  is  especially  impor- 
tant to  employ  the  most  rapid  methods  and  avoid  prolonging  the 
anaesthesia  or  the  operation. 

After  the  removal  of  the  tnmor  it  is  well  to  do  a  supplementary 
curettage,  either  at  the  same  sitting  or  at  the  end  of  a  few  hours,  and 
follow  it  with  cauterization,  to  cure  the  metritis,  which  is  constant, 
and  to  hasten  the  involution  of  the  enlarged  uterus  resulting  from  the 
presence  of  the  neoplasm. 

Submucous  Fibroma  of  the  Uterine  Body. — Clinically,  we  must  in- 
clude under  this  head  those  tumors  which  are  separated  from  the 


Fig.  144. — Forceps  for  Removal  of  Large  Tumors,    a,  With  adjustable  joint;  b,  pickerel  toothed. 


mucosa  by  a  layer  of  muscular  tissue,  for  they  are  more  closely  re- 
lated to  this  surface  than  to  the  peritoneum,  and  cause  a  decided  pro- 
jection into  the  cavity  of  the  organ.  At  certain  times,  during  men- 
struation, or  metrorrhagia  accompanied  by  colic,  the  cervix  is  more  or 
less  obliterated  and  opens  enough  to  allow  the  finger  to  pass  upward 
to  the  projection  of  the  tumor.  Artificial  dilatation,  in  default  of  the 
natural,  permits  us  to  appreciate  the  conditions  present.  An  urgent 
indication  for  immediate  interference  is  the  commencement  of  gan- 
grene. 

The  loose  connection  of  the  tumor  with  the  uterus,  and  the  many 
times  repeated  example  of  spontaneous  expulsion  by  natural  effort 
alone,  should  lead  the  surgeon  to  attempt  enucleation.  This  idea  was 
first  advanced  by  Velpeau,39  but  it  was  Amussat  who  did  the  first  op- 


MEDICAL   AND    SURGICAL   TREATMENT    OF    FIBROMA.  261 

eration,  and  made  it  his  own  by  the  zeal  and  talent  with  which  he 
defended  it  ;w  since  then  it  has  been  performed  by  Boyer,  Berard, 
Maisonneuve,  Lisfranc,  and  others.  But  after  a  momentary  favor  it 
fell  into  discredit  and  was  done  only  here  and  there  in  isolated  cases; 
the  criticisms  of  Jarjavay  and  Guyon  contributed  powerfully  to  this 
result.41  But  while  its  fortune  declined  in  France,  it  improved  else- 
where. Atlee 43  recommended  it  in  America  as  a  means  of  curing 
'•  tumors  till  then  considered  beyond  the  resources  of  art."  In  Eng- 
land and  Germany  also  Amussat's  operation  was  practised  for  a  long 
time,43  though  it  continued  to  have  its  warmest  partisans  in  America. 
It  was  but  little  practised  in  France,  when  my  fellowship  thesis  called 
attention  to  it  anew,  and  brought  out  new  observations,44  but  the  prog- 
ress of  laparatomy  has  almost  entirely  directed  surgeons  to  the  intra- 
peritoneal methods  (hysterotomy,  castration),  up  to  the  recent  reac- 
tion in  favor  of  the  vaginal  operation  of  Pean  and  his  admirers.45 

According  to  Schroder,  the  volume  of  the  tumor  which  may  be 
removed  by  enucleation  is  that  of  the  foetal  head  at  term ;  the  only 
other  case  is  where  the  neoplasm  descends  the  greater  length  of  the 
vaginal  canal. 

"We  shall  see,  however,  that  morcellation  of  the  tumors  permits  us 
to  reach  much  higher  up  the  vagina ;  and  it  is  only  when  the  tumors 
are  very  small  that  we  practise  enucleation  alone. 

Narrowness  and  rigidity  of  the  vagina  form  a  sufficient  contra-indi- 
cation  in  certain  cases ;  these  can  often  be   overcome  by  tamponing. 

In  the  absence  of  spontaneous  dilatation  of  the  cervix,  we  use  1am- 
inaria  tents  or  Hegar's  bougies  with  preliminary  bilateral  incision. 
Chrobak  prefers  multiple  incisions,  which  he  carefully  sutures  after 
the  operation.  If  the  tumor  surpasses  the  size  of  the  fist,  we  do  not 
attempt  to  enucleate  it  entire,  but  remove  it  preferably  in  small  por- 
tions. 

The  operation  varies  considerably  with  the  volume,  the  consistency, 
and  the  connections  of  the  fibrous  tumor. 

The  most  convenient  position  is  the  dorso-sacral,  but  certain  op- 
erators prefer  that  of  Sims.  Anaesthesia  is  necessary.  Two  assistants 
hold  the  legs  of  the  patient,  the  one  depressing  the  uterus  from  above 
the  pubes,  the  other  keeping  up  continuous  irrigation,  each  of  them 
holding  one  of  the  retractors.  It  is  well  to  have  another  assistant,  as 
the  operation  is  particularly  fatiguing. 

When  the  cervix  is  not  sufficiently  dilated,  there  should  be  no  hesi- 
tation in  splitting  it  up  to  the  vaginal  insertion,  after  having  ligated 


262 


CLINICAL   AND   OPERATIVE   GYNECOLOGY. 


the  lower  branches  of  the  uterine  artery  (p.  114) ;  this  is  the  preliminary 

step. 
•   If  the  tumor  is  small  and  the  cervix  is  not  too  much  thinned  to 

sustain  the  traction,  forceiDS  in  one  or  the  other  lip  render  valuable 
service  in  drawing  the  organ  down  and  furnishing  a  point 
of  support  for  the  enucleation. 

The  first  step  consists  in  opening  the  capsule.  The 
projecting  part  of  the  tumor  is  seized  by  a  Museux  for- 
ceps, and  at  the  point  where  the  mucous  membrane  is 
reflected  on  to  the  uterus  an  incision  is  made  with  a  bis- 
toury or  scissors  to  as  great  an  extent  as  possible. 

The  second  step  consists  of  peeling  the  capsule  from 
the  tumor  with  the  fingers ;  a  spatula  is  sometimes  nec- 
essary for  this  purpose.  It  should  be  dull  and  slightly 
concave;  I  have  devised  an  enucleator  in  the  form  of 
a  large  spoon  with  which  I  have  obtained  good  results 
(Fig.  145).  I  pref er  the  enucleator  of  Sims  to  the  toothed 
spoon  of  Thomas. 

When  the  adhesions  of  the  fibroma  have  been  de- 
stroyed over  a  certain  area,  the  Museux  forceps  are  re- 
applied, and  with  these  or  double  hooks  the  tumor  is 
rotated  on  its  axis;  if  it  is  necessary,  curved  scissors  may 
be  used  to  divide  the  fibrous  bands  which  do  not  yield  to 
the  enucleator. 

The  third  step,  or  removal  of  the  tumor,  is  not  so 
laborious  as  it  is  extensive.  I  have  removed  in  mass  an 
intra-uterine  fibroma  larger  than  the  fist,  which  was  not 
in  a  capsule,  but  free  in  the  uterine  cavity,  where  it 
had  formed  adhesions.  It  was  in  a  very  curious  case  of 
polyp  with  intermittent  symptoms  which  had  not  been 
removed,  though  frequently  coming  down  into  the  vagina, 
and  which  finally  was  retracted  into  the  uterus,  where 

fig.  i45.-Pozzrs  ft  became  secondarily  fixed.46 

Enucleator.  .  .  „ , 

Frankenhauser  has  invented  for  the  extraction  ot  large 
tumors  a  special  instrument  resembling  the  cephalotribe,  and  Martin 
a  kind  of  tongs  with  a  forceps  joint.  P.  Segond  has  an  instrument 
which  permits  the  extraction  of  part  of  the  tumor  as  a  core  (Fig. 
146).  C.  Braun  uses  a  cranioclast  to  reduce  the  size  of  voluminous 
tumors. 

When  the  fatigue  of  the  operator  or  the  debility  of  the  patient 


MEDICAL   AND   SURGICAL   TREATMENT   OF   FIBROMA. 


263 


has  made  it  necessary  to  arrest  the  operation  before  it  is  completed,  the 
spontaneous  elimination  of  the  tumor  has  been  observed  at  the  end  of 
a  few  days,  and  sometimes  a  second  operation  is  far  less  difficult, 
owing  to  the  infiltration  of  the  capsule  and  the  relaxed  adhesions. 
This  latter  fact  has  given  the  idea  to  certain  operators  of  spreading  the 
operation  over  different  sessions  (Matthews  Duncan,47  Marion  Sims). 
But  this  is  to  make  a  matter  of  choice  of  what  should  be  only  a  con- 
dition of  necessity,  and  expose  the  patient  to  the  septic  accidents 
which  have  so  often  followed  such  treatment.  There  is  another 
variety  of  operation  in  two  sessions,  where  the  first  consists  merely 
of  a  deep  incision  of  the  capsule,  after  the  example  of  Atlee ; 48  then 
after  some  days,  when  we  may  suppose  that  the  uterine  contractions 
have  produced  a  partial  separation  of  the  tumor,  we  may  proceed  to 
enucleation.     Vulliet 49  has  recently  perfected  this  procedure  of  Atlee. 


Fig.  146.— Segoxd's  Trephine  for  Morcellation  of  Fibroids. 

He  attempts,  a  little  theoretically,  to  direct  the  fibroma  at  its 
first  appearance  toward  the  uterine  cavity,  rather  than  toward  the 
abdominal,  by  the  aid  of  a  galvanic  current ;  then,  when  it  has  be- 
come submucous,  the  capsule  is  incised  and  ergot  and  electricity  are 
employed  to  increase  its  tendency  toward  self-enucleation,  and  to 
this  are  added  intra-uterine  tampons  of  iodoform  gauze,  renewed  every 
forty-eight  hours. 

The  objections  to  this  method  are  its  extreme  slowness,  the  many 
dangers  to  which  it  exposes  the  uterus,  and  the  uselessness  of  long 
temporization  with  a  tumor  which  has  become  accessible  to  oper- 
ation.30 

If  it  is  impossible  to  remove  the  whole  of  the  tumor  without  dan- 
gerous violence,  we  may  leave  a  portion  of  it,  hoping  that  by  anti- 
septic treatment  (iodoform  tampons  and  intra-uterine  injections, 
etc.)  we  may  prevent  the  septicaemia  which  might  be  caused  by 
gangrene   of  the  portion  left  in  place;  but  incomplete  removal  has 


264  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

given  rise  to  serious  disaster  when  antiseptic  precautions  have  not 
been  observed.  Although  the  result  may  at  any  time  be  disappoint- 
ing, we  may  still  hope  to  realize  one  of  the  following  effects:  either 
the  spontaneous  expulsion,51  more  or  less  tardy,  or  the  retraction 
and  atrophy  of  the  intra-uterine  portion.52  After  the  enucleation  of 
intra-uterine  fibroma,  there  is  left  a  large  bleeding  cavity  contain- 
ing loosely  attached  portions  of  capsule  of  tumor,  in  a  more  or  less 
completely  relaxed  uterus.  All  loose  pieces  should  be  removed  from 
the  wound,  and  hot  antiseptic  injections  employed.  On  account 
of  the  large  absorbing  surface,  it  is  better  to  use  a  solution  of  car- 
bolic acid,  one  to  fifty,  rather  than  bichloride  which  may  cause  toxic 
syptoms.  If  there  is  much  oozing,  the  temperature  of  the  injections 
should  be  raised  to  120°  F.  (50°  Cent.)  and  the  cavity  may  be  packed- 
with  iodoform  gauze.  A  hypodermic  of  ergotin,  with  massage  over 
the  hypogastrium,  will  bring  on  uterine  contractions.  Then  several 
layers  of  cotton  and  a  bandage  are  applied,  and  the  patient  ordered 
absolute  rest. 

The  principal  accidents  of  enucleation  are  hemorrhage,  wounds 
of  the  uterine  wall,  inversion  of  the  uterus,  and  septicaemia. 

For  the  hemorrhage  the  best  remedy  is  rapid  completion  of  the 
operation,  for  the  retraction  of  the  uterine  walls  will  stop  the  bleed- 
ing. If  necessary  we  may  compress  the  abdominal  aorta  and  tampon 
the  uterus.53 

Perforation  is  not  very  serious  unless  there  is  septic  infection  of 
the  cavity,  without  which  an  adhesive  peritonitis  closes  the  wound 
as  after  vaginal  hysterectomy. 

Inversion  of  the  uterus  may  be  produced  during  the  operation 
from  excessive  traction.  It  renders  the  tumor  more  accessible  to  the 
manipulations  of  the  surgeon,  but  is  dangerous  if  unrecognized,  for 
it  may  lead  our  efforts  in  a  false  direction.  After  the  operation,  the 
thinness  of  the  uterine  wall  where  the  tumor  was  situated  may  pro- 
duce a  consecutive  inversion ;  Bischoff 54  in  such  a  case  produced  a 
gradual  reposition  by  tamponade. 

Septicaemia,  with  its  different  local  manifestations,  metro-perito- 
nitis, thrombosis,  etc.,  may  follow  when  there  is  a  large  cavity  without 
much  retraction  of  the  uterine  wall;  it  is  then  necessary  to  employ 
repeated  antiseptic  injections.  A  permanent  drainage  tube  of  rubber 
made  in  the  shape  of  a  cross  may  be  left  in  the  cavity,  where  it  is  re- 
tained without  exercising  pressure  (Fig.  52). 

Where  the  secretion  is  very  abundant  and  putrid,  continuous  irri- 


MEDICAL    AXD    SURGICAL    TREATMENT    OF    FIBROMA.  265 

gation  may  be  employed,  the  flow  being  only  drop  by  drop.  This 
weak  current  may  be  regulated  with  the  aid  of  Schiicking's  ingenious 
apparatus  fitted  to  the  discharge  tube  of  a  container  full  of  carbolic 
acid,  one  to  fifty,  and  attached  to  the  drainage  tube  (Fig.  56). 

As  West 55  and  Gillette 56  have  remarked,  it  is  impossible  to  obtain 
an  exact  idea  of  the  gravity  of  this  operation  from  statistics ;  for  some 
concern  only  successful  cases,  others  include  very  different  kinds  of 
operation,  complete  and  incomplete  enucleations,  those  divided  over 
different  sessions  with  tumors  gangrenous  or  otherwise,  with  or  with- 
out antiseptics,  etc. 

Moreover,  the  word  enucleation  does  not  have  the  same  meaning 
with  different  authors.  To  judge  correctly  of  this  operation,  as  of 
all  others,  we  should  have  a  series  of  individual  cases  from  surgeons 
of  an  average  skill,  established  by  homologous  observations.  If 
such  information  is  lacking,  we  must  content  ourselves  with  the  scat- 
tered notices,  some  of  them  incomplete,  accumulated  in  the  medical 
periodicals.  Thus,  in  1875 37 1  published  6-i  cases,  with  16  deaths,  that 
is,  2ofc;  Gusserow58  collected  154  cases  since  Amussat's,  up  to  1877, 
with  51  deaths,  that  is,  33$ ;  Lomer,59  who  restricted  his  inquiries  to 
the  antiseptic  period  (from  1873  to  1883),  found  in  130  cases  18 
deaths,  that  is,  16,<.  Adding  to  Lomer's  statistics  several  more  recent 
cases,  Gusserow  collected  153  cases,  with  23  deaths,  or  14.6fc\  from 
this  it  appears  how  greatly  the  fatality  of  the  operation  has  been 
lessened  by  antisepsis.  A.  Martin 60  has  published  personal  statistics 
which  have  an  unusual  value  because  of  his  skill,  and  the  oppor- 
tunity he  has  had  in  a  large  practice  to  compare  this  operation 
with  others  done  through  the  abdomen  for  analogous  cases.  In 
27  operations  he  had  but  5  deaths,  of  which  two  were  from  wounds 
of  the  peritoneum  and  peritonitis,  two  from  septicaemia  (before  the 
antiseptic  era),  and  one  from  collapse.  Martin  declares  that  he  has 
entirely  abandoned  vaginal  enucleation  for  tumors  of  the  body  of 
the  uterus,  even  though  they  are  in  partial  expulsion;  preferring 
extraction  through  the  abdomen,  where  he  makes  an  actual  enuclea- 
tion, as  far  as  the  integrity  of  the  uterus  is  concerned,  as  we  shall  see 
farther  on. 

I  agree  with  Martin  in  thinking  that  it  is  wrong  to  carry  the  va- 
ginal operation  too  far;  tumors  which  reach  to  the  umbilicus  should 
certainly  be  removed  by  laparatomy.  Nevertheless,  enucleation,  with 
or  without  morcellation,  remains  a  valuable  and  relatively  benign  re- 
source for  fibroma  of  the  cervix  or  the  lower  portion  of  the  uterine 


266  CLINICAL   AND    OPERATIVE   GYNECOLOGY. 

body,  which  do  not  exceed  in  size  the  foetal  head,  and  where  the  cervix 
has  already  began  to  dilate. 

Trans-vaginal  Enucleation. — If  the  myoma  starts  from  the  sn- 
pra-vaginal  portion  of  the  cervix  or  the  posterior  surface  of  the  uterus, 
it  may  make  the  posterior  wall  of  the  vagina  prominent  to  such  a  de- 
gree that  the  most  direct  way  to  reach  it  is  by  incision  of  that  wall ; 
less  often  the  incision  may  be  made  through  the  anterior  vaginal 
pouch.  In  these  cases  the  most  rational  operation  is  free  incision  of 
the  vagina.  This  procedure  may  be  relatively  simple  when  the  tumor 
is  posterior,  for  it  is  then  developed  in  the  pelvic  connective  tissue 
outside  of  the  peritoneum.  Czerny 61  reports  many  successful  cases 
with  this  method;  Ljocis  and  Olshausen62  have  published  similar 
cases.  Le  Fort 63  reported  a  curious  case  where  the  recto-vaginal  sep- 
tum was  split  from  above,  simulating  rectocele,  by  a  pedicled  fibroma 
whose  enucleation  through  the  perineum  was  followed  by  cure. 
Marc  See  on  this  occasion  cited  a  similar  case  without  a  pedicle.  Eu- 
gene Bockel, 64  in  a  case  where  the  fibroma  was  accessible  through  the 
vagina,  made  a  median  incision  through  that  canal  and  the  cervix, 
posteriorly,  and  successfully  enucleated  the  tumor. 

When  the  tumor  is  very  large,  both  morcellation  and  enucleation 
may  be  required.  When  the  fibroma  projects  both  toward  vagina 
and  peritoneum,  the  serous  membrane  may  be  opened,  which  compli- 
cates the  operation  and  renders  it  more  grave;  many  such  cases  have 
been  followed  by  peritonitis,  with  a  fatal  termination, 65  but  there 
are  other  such  cases  which  were  successful.66 

Morcellation  or  Vaginal  Myomotomy. — The  difficulty  of  enucle- 
ating the  tumor  when  it  is  of  large  size  or  is  closely  connected  with  the 
uterine  tissue  on  the  one  hand,  and  the  gravity  of  opening  the  abdo- 
men compared  with  the  vaginal  method  on  the  other,  have  led  sur- 
geons to  remove  large  tumors  in  successive  fragments  by  the  vagina 
through  the  partly  effaced  cervix,  either  by  natural  dilatation  or  by 
incision. 

Emmet,67  in  America,  has  devised,  under  the  name  of  "  extraction 
of  fibroma  by  traction,"  a  procedure  which  he  has  practised  since  1884. 
His  object  is  to  produce  a  pedicle  by  traction  on  the  tumor,  which 
he  then  removes  by  a  combination  of  morcellation  and  enucleation, 
but  he  describes  his  technique  in  so  incomplete  a  manner  that  it  is 
difficult  to  form  precise  ideas  about  it.  The  isolated  cases  of  Czerny 
and  other  German  surgeons  lack  quite  as  much  definite  synthesis  and 
method. 


MEDICAL  AND   SURGICAL  TREATMENT   OF  FIBROMA.  267 

On  the  other  hand,  this  criticism  cannot  be  made  of  the  technique 
which  Pean  has  made  known  even  in  the  smallest  details  by  a  series 
of  publications  which  have  been  collated  by  Secheyron.68  The  funda- 
mental idea  of  this  method  is  the  employment  of  morcellation  from 
the  first,  without  the  addition  of  enucleation.  Instead  of  attacking 
the  tumor  at  its  periphery,  the  surgeon  begins  immediately  upon  the 
central  portion  and,  after  that  is  fully  excised,  finally  reaches  the 
fibrous  shell :  moreover,  Pean's  method  includes  a  special  preliminary 
operation  of  splitting,  and,  at  the  same  time,  excising  the  cervix  to 
obtain  easy  access  to  the  fibroma. 

The  cases  to  which  morcellation  by  the  vagina  may  be  applied 
comprise  not  only  submucous  tumors  of  the  size  of  the  infant  or  adult 
head,  but  also  cases  of  interstitial  and  subperitoneal  tumors  for  which 
laparatomy  might  be  fatal  because  of  the  large  opening  made  in  the 
serous  membrane.  In  certain  cases,  moreover,  Pean  has  completed 
the  operation  by  total  ablation  of  the  uterus  either  by  the  vagina  or 
through  the  abdominal  walls.69  That  seems  to  me  an  exaggerated 
extension  of  the  operation  which  may  be  dangerous ;  the  weak  point 
in  the  procedure  is  in  the  difficulty  of  determining  the  limits  to 
which  we  may  go,  and  in  the  possibility  of  needing  to  do  a  hysterec- 
tomy after  having  already  performed  a  laborious  operation. 

The  operation  is  divided  into  three  steps:  1.  Freeing  the  cervix 
from  its  vaginal  attachments.  2.  Section  of  the  cervix  and  a  segment 
of  the  uterus  at  the  level  of  the  tumor;  3.  Removal  of  the  tumor  by 
small  pieces,  with  or  without  enucleation;  and  excision  and  suture  of 
the  lips  of  the  cervix. 

For  this  operation,  Pean  uses  a  series  of  forceps  either  straight  or 
curved,  with  long  jaws,  flat,  toothed  or  not,  without  points,  round  or 
blunt,  especially  designed  for  morcellation  (Figs.  148  and  149) ;  and, 
lastly,  he  is  provided  with  long-  or  short-handled  f orcipressure  forceps. 
The  preliminary  steps  are  the  same  as  those  of  all  gynaecological 
operations. 

The  patient  is  placed  in  the  left  lateral  or  dorsal  position.  Besides 
the  two  assistants  at  right  and  left  of  the  operator,  a  fourth  is 
placed  on  a  foot-stool  on  a  little  lower  plane,  to  help  in  holding  the 
retractors. 

First  Step — Liberation  of  the  Cervix. — Two  or  three  elbowed 
retractors  display  the  cervix  at  the  bottom  of  the  vagina;  this  is  im- 
mobilized with  strong  Museux  forceps;  a  circular  incision  is  made 
with  a  bistoury  at  the  level  of  the  vaginal  insertion,  hemostatic  for- 


268  CLINICAL   AND   OPEKATIVE   GYNAECOLOGY. 

ceps  being  placed  upon  the  bleeding  vessels  as  necessary.  It  is  at 
this  point  in  the  operation  that  the  forceps  are  the  most  necessary, 
for,  before  completing  it,  it  is  necessary  to  stop  the  bleeding  entirely. 
When  the  cervix  is  free  enough  above,  it  is  cut  almost  through  with 
a  bistoury  in  order  not  to  wound  either  bladder  or  ureters;  it  is  then 
very  movable,  swinging  as  freely  as  the  pendulum  of  a  clock. 

In  this  part  of  the  operation  we  must  take  care  not  to  wound  the 
peritoneum,  though  that  accident  has  not  the  gravity  which  has  been 
attributed  to  it:  in  some  cases  even,  according  to  Peah,  it  is  advised 
to  make  this  perforation  in  order  to  reach  a  fibroma  projecting  into 
the  cul-de-sac. 

Second  Step — Incision  of  Cervix  and  Segment  of  Uterus  below 
Fibroma. — Long,  straight  scissors  with  blunt  points  are  introduced 
into  the  cervical  cavity,  and  a  clean  bilateral  incision  is  made.  A 
Museux  forceps  is  then  placed  on  each  one  of  the  lips,  anterior  and 
posterior.  The  finger  introduced  into  the  cavity  determines  the  exact 
seat  of  the  tumor  and  the  point  where  it  is  most  easily  accessible, 
which  is  distinguished  from  the  uterine  wall  by  its  white  or  violet 
color  and  its  density.  During  this  examination  the  organ  should  be 
drawn  well  downward. 

Third  Step — Fractional  Excision  of  the  Tumor. — The  tumor  pro- 
jects toward  the  cavity  of  the  uterus,  the  peritoneum,  or  the  vagina  ; 
it  is  drawn  downward  by  steady  traction  with  a  Museux  forceps,  or 
by  long  forceps  with  flat  teeth  fenestrated  or  furnished  with  points 
(Figs.  148, 149).  The  elbowed  retractors  are  then  introduced,  the  large 
ones  into  the  vagina,  and  smaller  ones  into  the  uterus,  displaying  the 
operative  field  as  widely  as  possible.  These  retractors  not  only  make 
the  part  accessible,  but  also  form  a  valuable  means  of  controlling  the 
hemorrhage  by  the  pressure  and  traction  which  they  exert.  If  neces- 
sary, an  electric  light  may  be  used  to  illumine  the  part  operated  on. 

The  fibroma  is  fixed  by  the  finger,  seized  with  the  forceps,  and 
drawn  strongly  down.  A  piece  of  it  is  then  grasped  by  a  strong- 
toothed  forceps,  and  a  deep  incision  perpendicular  to  the  long  axis  of 
the  tumor  is  made ;  each  of  the  lips  of  the  section,  or  perhaps  but  one 
of  them,  is  grasped  as  high  as  possible  with  a  strong-toothed  or 
pointed  forceps  and  the  subjacent  parts  excised.  Before  the  first  for- 
ceps is  removed,  a  second  pair  is  passed  above  it,  grasping  a  new  por- 
tion of  the  myoma,  and  the  scissors  or  the  bistoury  cut  out  the  part 
below;  thus  by  the  aid  of  the  forceps,  bistoury,  and  scissors  the  tumor 
is  excised  portion  by  portion  (Fig.  147). 


MEDICAL   AND    SURGICAL   TREATMENT   OF   FIBROMA.  269 

The  bistouries  which  Peari  uses  are  of  special  make  and  very 
strong,  resembling  metacarpal  knives,  either  straight  or  curved  on  the 
flat,  and  with  long  handles. 

Very  often  the  procedure  is  simpler;  the  tumor  may  not  bleed, 
and  then  the  forceps  are  used  only  to  draw  down  different  parts  of  it, 
the  portions  between  its  jaws  being  cut  out  in  turn.  This  excision  is 
practised  alternately  flrst  on  one  side  of  the  tumor,  then  on  the  other; 
and  as  the  operation  progresses  the  traction  allows  us  to  remove  larger 
fragments,  which  may  be  as  large  as  a  nut,  or  even  as  an  apple. 


Fig.  147.— Removal  of  Fibroma  by  Morcellation  (after  Pean). 

Thus  successive  fragments  are  removed,  the  operation  lasting  perhaps 
an  hour. 

When  the  lower  part  of  the  tumor  has  thus  been  removed,  it  is 
often  possible  by  traction  and  rotation  to  produce  spontaneous  ex- 
pulsion of  the  upper  portion,  which  will  shorten  the  time  of  operation 
considerably.  The  volume  of  the  mass  enucleated  by  traction  alone 
may  exceed  that  of  the  portion  excised. 

When  the  fibroma  is  of  large  size,  the  intra-muscular  cavity  which 
held  it  is  almost  always  widely  opened,  communicating  with  the  in- 
terior of  the  uterus  and  the  peritoneum,  and  bleeding  so  freely  that 


270 


CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 


the  important  vessels  require  ligation.  This  step  of  the  operation 
demands  the  dissection  of  almost  the  whole  lower  portion  of  the 
uterus,  and  its  infra- traction  almost  to  the  vulva ;  to  facilitate  this, 
Pean  excises  the  two  cervical  lips,  and  sutures  them  afterward  to  the 


Fig.  148. — Dentated  Cyst  Forceps  ■which  may  be  Employed  for  Mo"ceixation. 

lips  of  the  vaginal  wound  with  metallic  sutures.    As  to  any  communi- 
cation with  the  peritoneal  cavity,  Pean  leaves  it  open  if  its  edges  are   ' 
much  contused,  though  he  narrows  it  by  a  few  sutures  at  separate 
points.70 

It  is  easy  to  determine  when  the  myoma  has  been  completely  ex- 


Fio.  149.— -Pean's  Forceps,  Serrated  and  with  Teeth,  for  Morcellation  of  Fibromata. 

tracted,  for  the  last  portions  present  a  convex,  smooth,  and  red  surface, 
covered  with  cellular  debris.  The  operation  is  not  complete  until 
the  state  of  the  adjacent  uterine  tissue  has  been  examined  by  the 
finger.  If  another  myoma  is  found  near  the  first,  it  should  be  at  once 
removed;  for  this  purpose  a  larger  incision  of  the  uterus  may  be 
made  with  a  bistoury  if  necessary.     The  second  tumor  is  then  strongly 


MEDICAL   .VXD    SURGICAL   TREATMENT    OF   FIBROMA  271 

grasped  with  forceps  and  removed  as  before.  Thus  the  operator  may 
be  obliged  to  extract  a  series  of  small  tumors  hidden  away  in  the 
parenchyma. 

Fourth  Step — The  Uterine  Toilet  and  Suture  of  the  Cervix. — As 
the  tumor  is  removed  it  leaves  a  large  pocket  which  communicates 
freely  with  the  uterine  cavity; from  this  hang  the  haemostatic  f orceps 
with  long  handles  to  the  number  of  twelve  to  twenty.  During  the 
operation  Pean  uses  small  sponges  provided  with  long  handles  to 
cleanse  the  walls  of  the  part  and  find  the  bleeding  points;  T  replace 
these  with  pledgets  of  absorbent  cotton.  The  last  step  of  the  opera- 
tion is  the  thorough  cleansing  of  the  wound ;  the  smaller  clots  are 
removed,  and  between  the  forceps  left  to  control  the  bleeding  (from 
ten  to  fifteen)  it  is  well  to  pack  strips  of  iodoform  gauze.  Intra- 
uterine irrigation  with  hot  antiseptic  fluid  should  precede  the  appli- 
cation of  these  tampons,  and  after  thirty-six  to  forty-eight  hours  the 
forceps  are  removed.  Where  the  tumor  is  small  the  operation  may 
be  finished  by  suturing  the  lips  of  the  cervix.  During  the  first  days 
after  the  operation  it  is  well  to  give  small  doses  of  ergot. 

It  is  difficult  to  pronounce  upon  the  gravity  of  this  method. 
Pean  has  not  published  his  whole  statistics;  Terrillon, T1  with  five 
operations,  succeeded  five  times ;  Bouilly  had  four  out  of  five  success- 
ful cases ;  in  the  single  case  where  I  performed  it  I  obtained  a  cure. 
It  seems  to  me  certain  that  this  bold  procedure  ought  to  give  excel- 
lent results  whenever  the  tumor,  though  of  large  size,  is  submucous 
or  interstitial  and  furnished  with  a  capsule  which  permits  us  to  limit 
the  operation  by  a  clean  extraction  of  the  upper  part  of  the  fibrous 
sphere.  But  if  one  attacks  a  subperitoneal  tumor,  either  at  the  outset 
or  secondarily,  which  is  intimately  fused  with  the  uterine  paren- 
chyma, so  that  nothing  marks  the  boundary  between  the  pathologi- 
cal and  the  normal  tissue,  it  is  plain  that  the  operation  may  become 
very  grave  and  lead  to  a  fatal  hysterectomy  by  the  vagina  performed 
under  unfavorable  conditions.  Mikulicz, 72  after  inverting  the  uterus 
at  an  operation,  resected  a  portion  of  its  wall  to  remove  a  tumor  of 
this  kind,  then  sutured  the  peritoneal  wound  with  catgut  for  a  dis- 
tance of  10  cm.,  and  finally  returned  the  organ  to  its  place;  the  patient 
recovered ;  but  this  case  of  bold  surgical  skill  should  hardly  establish 
a  precedent. 

It  is  not  enough  that  an  operation  should  be  possible,  and  at  the 
same  time  produce  brilliant  results,  to  make  it  advisable;  it  must 
also  be  decidedly  preferable  to  other  operations  of  a  less   serious 


272  CLINICAL   AND    OPERATIVE    GYNAECOLOGY. 

nature  which  may  be  performed  in  the  same  case.  In  the  absence  of 
comparative  statistics  it  does  not  seem  probable  that  fractional  exci- 
sion of  large  myomata  by  the  vagina  is  simpler  and  less  dangerous 
than  hysterectomy  or  enucleation  by  the  abdomen  (Martin).  Possi- 
bly the  surgeon's  own  preferences  would  decide  the  question.73 

Vaginal  Hysterectomy. — Total  ablation  of  the  uterus  for  fibrous 
tumors  has  been  advised  in  two  different  conditions:  1.  In  case  of 
small  simple  or  multiple  tumors,  which  are  the  cause  of  grave  symp- 
toms. 2.  In  the  case  of  large  tumors  when,  at  the  end  of  an  operation 
for  their  fractional  removal,  it  becomes  evident  that  a  portion  of  the 
uterine  wall  requires  excision.  In  the  latter  case  it  is  an  operation  of 
necessity.  In  the  case  of  smaller  tumors,  on  the  contrary,  hysterec- 
tomy is  not  a  necessity  and  has  but  few  partisans,  the  majority  of 
surgeons  preferring,  I  think,  a  less  serious  operation,  namely,  castra- 
tion. It  seems  here  again  that  individual  tendencies  preponderate ; 
thus,  for  example,  Pean  performs  vaginal  hysterectomy,  which  he 
calls  "uterine  castration,"  for  the  very  cases  where  another  would 
perform  an  abdominal  hysterectomy,  and  still  another  an  ovarian 
castration.  As  a  matter  of  fact  the  three  operations  have  equal 
chances  of  success  in  the  only  case  where  there  is  any  hesitation  be- 
tween them,  namely,  in  small  multiple  fibromata  of  grave  symptoms. 

Although  colpo-hysterectomy  had  already  been  done  by  Kottmann,74 
Pean 75  was  the  first  to  perform  it  in  France  systematically.  Demons 76 
has  also  advocated  it.  Successful  cases  have  been  published  by 
Sanger,  Orthmann,  Richelot,  Terrier,  Spath,  and  Leopold.77  According 
to  Gavilan,  in  40  cases  of  vaginal  hysterectomy  there  were  2  deaths ; 
that  is,  14.29 fo.    Leopold  in  17  operations  had  but  2  deaths;  11.7$. 

The  operative  technique  is  that  which  I  describe  for  the  same 
operation  in  cancer,  with  but  this  difference,  that  fractional  excision 
does  not  offer  any  risk  of  infecting  the  wound,  the  neoplasm,  except 
at  suppurating  or  gangrenous  points,  not  being  septic.  To  facilitate 
removal  of  the  tumor,  a  part  of  it  may  need  extraction,  the  vagina  and 
vulva  may  require  to  be  dilated  previously  (Pean),  or  the  perineum 
may  require  incision  (Mikulicz  and  Leopold),  which  is  repaired  with 
care  at  the  end  of  the  operation.  If  hysterectomy  is  performed,  it 
must  be  absolutely  complete,  without  leaving  any  portion  of  the  uter- 
ine tissue  adherent  to  the  broad  ligament;  decomposition  of  such  por- 
tions has  caused  death  by  septic  peritonitis  in  one  of  Terrier's  cases.78 

This  method  of  treatment,  it  seems  to  me,  should  be  reserved  for 
cases  where  the  uterus  is  relatively  small  but  exerts  pressure  on  im- 


MEDICAL   AND   SURGICAL   TREATMENT   OF   FIBROMA.  273 

portant  organs,  .and  may  be  extracted  without  much  effort  by  the 
natural  passages,  with  easy  ligature  of  the  broad  ligaments.  It  is 
only  in  such  conditions  that  the  operation  is  benign  and  may  be  sub- 
stituted for  abdominal  hysterectomy.  More  definitely,  I  would  ad- 
vise colpo-hysterectomy  where  the  uterus  does  not  exceed  the  volume 
of  the  fist,  and  also  in  the  following  circumstances :  1st,  Hemorrhage 
threatening  to  become  rapidly  fatal ;  2d,  serious  compression  (ureter, 
bladder,  nerves,  rectum)  exerted  by  a  small  pelvic  fibroma,  upon 
whose  development  the  indirect  action  of  castration  would  not  soon 
enough  exert  sufficient  influence.  In  all  other  cases,  if  the  tumor 
may  not  be  enucleated  by  the  vagina  or  the  abdomen,  I  prefer  castra- 
tion in  case  of  hemorrhage  and  abdominal  hysterectomy  when  the  size 
and  connections  of  the  tumor  demand  its  complete  extirpation.  In 
spite  of  the  undeniable  dangers  of  laparatomy  a  sinrple  abdominal 
hysterectomy  is  always  less  serious  than  a  protracted  vaginal  hyster- 
ectomy. (The  operation  with  resection  of  the  sacrum  may  prove  ad- 
visable with  many  pelvic  fibrous  tumors,  for  which  hysterectomy  was 
formerly  practised.  For  the  technique  Of  the  operation,  which  in 
gynaecology  has  been  applied  chiefly  to  the  treatment  of  uterine  can- 
cer, I  refer  to  its  own  special  chapter.) 

Destruction  of  the  Fibroma  through  the  Vagina.— I  include 
under  this  title  several  operations  which  do  not  belong  in  the  previ- 
ous categories,  but  which  should  nevertheless  be  described,  though 
only  as  a  matter  of  history: 

Partial  Destruction  by  Incisions. — Baker  Brown 79  has  attempted 
to  copy  the  natural  processes  which  at  times  cure  the  fibroma  by  gan- 
grene and  consecutive  elimination.  His  method  is  as  follows:  Incision 
of  the  capsule ;  introduction  into  the  depths  of  the  tumor  of  special 
scissors  cutting  on  their  outer  edge,  and  dilaceration  of  the  morbid 
mass  or  ablation  of  a  conical  fragment;  or  perf oration  by  a  kind  of 
trephine. 

Partial  Destruction  by  Cauterization. — Greenhalgh,80  with  the 
same  object,  opened  the  capsule  with  a  hot  iron,  establishing  suppura- 
tion, removing  debris  by  the  hand ;  in  case  of  retro-vaginal  tumor  he 
pierced  it  in  different  places  with  the  hot  iron  over  the  projecting  por- 
tions ;  in  two  cases  out  of  three  death  followed  from  peritonitis. 

In  the  case  of  tumors  which  seemed  inaccessible,  above  the  pubes, 
Kceberle 81  has  dilated  the  cervix  and  made  a  series  of  parallel  inci- 
sions into  the  tumor,  filling  them  with  enough  perchloride  of  iron  to 
determine  the  mortification  of  the  intervening  portions. 


274  CLINICAL   AND    OPERATIVE   GYNECOLOGY. 


BIBLIOGRAPHY. 

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19.  Terrillon :   Bull,  de  la  Soc.  de  Chir.,  1889,  p.  475. 

20.  Ibid.,  p.  473. 

21.  Ibid.,  p.  542. 

22.  Trans.  Obst.  Soc  of  New  York,  January  18th,  1887.  Amer.  Journal  Obst., 
1887,  p.  290.     Emmet  strongly  opposed  the  use  of  electricity;  Freeman  defended  it. 

23.  British  Gyn.  Soc,  Session  of  May,  1888.  Lawson  Tait,  Bantock,  and  many 
others  condemned  electricity;  Routh,  Spencer  Wells,  Playfair,  Aveling,  Skene 
Keith,  etc.,  approved  of  it  more  or  less.    Brit.  Gyn.  Jour.,  1888. 

24.  Gyn.  Gesell.  z.  Berlin,  March  8th,  1889.     Centr.  f.  Gyn.,  1889,  No.  16. 

25.  D.  Angel  Villa  :  Th6rap.  Compar.  des  Fibr.  Nouv.  Arch.  d'Obst.,  January 
25th,  1888,  p.  10. 

26.  This  remark  was  made  by  Halliday  Crooin.     Amer.  Jour.  Med.  Sci.,  Dec, 


MEDICAL   AND   SURGICAL   TREATMENT    OF   FIBROMA.  275 

1888,  and  by  Dtihrssen  :   Discus,  at  Soc.  Obstet.  and  Gyn.,  Berlin,  March  8th,  1889. 
Analysis  in  Centr.  f.  Gyn.,  1889,  No.  16. 

27.  Coe  :  Med.  Record,  Jan.  13th,  1888.  Runge  :  Arch.  f.  Gyn.,  Band  xxxiv.. 
Heft  3,  1889. 

28.  Kaltenbach:   Centr.  f.  Gyn.,  1888,  p.  729. 

29.  A.  Villa  :  Loc.  cit.,  p.  576. 

30.  A.  Martin  :  Path,  und  Ther.  der  Frauenk.,  p.  275. 

31.  Lisfranc  :  Cliniques,  vol.  iii.,  pp.  172,  178,  179. 

32.  Tillaux:  Annales  de  Gynecologie,  ii.,  p.  461. 

33.  Trelat:  Gaz.  Hebdom.,  October  21st,  1881. 

34.  S.  Pozzi :   Revue  de  Chirurgie,  February,  1885. 

35.  Simon  :   Monatschrift,  xx.,  25. 

36.  Hegar  and  Kaltenbach  :    Loc.  cit.,  French  ed.,  p.  414. 

37.  Velpeau  and  Chassaignac  :  Bull,  de  la  Soc.  Anatoin.,  1833,  p.  113. 

38.  Heywood  Smith  and  Barnes  :  Transac  of  the  Obstetric.  Society  of  London, 
1881,  Arol.  xxiii.,  p.  233.     Koeberle  :  Gazette  m^d.  de  Strasbourg,  1888,  No.  4. 

39.  Auguste  Berard  :  Gaz.  des  Hopitaux,  1842,  p.  18. 

40.  Ainussat :  Revue  Med.,  August,  1840,  and  Mem.  sur  FAnatomie  Pathol,  des 
Turn.  Fibr.  Interstit.,  etc.,  Paris,  1842. 

41.  Jarjavay:  Paris  Thesis,  1850.     Guyon  :  Paris  Thesis,  1860. 

42.  Atlee :  Surgical  Treatment  of  Certain  Fibroid  Tumors,  etc.,  Phila.,  1853. 
Baker  Brown  :  Obstetric.  Trans.,  London,  iii.,  1862.  Duncan  :  Edinb.  Med.  Jour., 
February,  1867.  Maenel :  Prag.  Vierteljahr.,  1874,  Band  ii.,  page  29.  A.  Martin: 
Zeit.  f.  Geb.,  1876,  p.  143.  C.  Braun  :  Wien.  ined.  Woch.,  1874,  Nos.  39-41.  One  of 
the  most  complete  works  on  the  subject  is  by  Lomer  :  Zeits.  f.  Geburts.,  Bd.  ix.,  p. 
277.  Analysis  in  Union  Medicale,  Oct.  9th,  1883.  Chrobak:  Med.  Jahrb.  der  k,  k. 
Gesell.,  Wien,  1888,  vol.  iii.,  p.  531. 

43.  Marion  Sims  :   New  York  Med.  Jour.,  1874. 

44.  Dezanneau  :  Bull,  de  la  Soc.  de  Chir.,  Jan.  11th,  1882.  Duret :  Journal  de 
Soc.  Med.  de  Lille,  August,  1889. 

45.  Pean  :  Gaz.  des  Hopit.,  1886,  pp.  445  and  1,169,  and  Ablat.  de  Pet.  Turn. 
Fibr.  par  le  Vagin.,  Paris,  1883,     Secheyron:  Trait.  d'Hyst,  etc.,  Paris,  1889,  p.  157. 

46.  S.  Pozzi :   Bull,  de  la  Soc.  de  Chir.,  Nov.  5th,  1884. 

47.  M.  Duncan  :  Edinb.  Med.  Jour.,  January  and  February,  1867. 

48.  Atlee  :  Aiuer.  Jour,  of  Med.  Sci.,  April,  1845,  and  October,  1856. 

49.  Vulliet :  Contr.  a  FEtude  du  Trait,  des  Fibro-myom.,  etc.  Arch,  de  Tocol., 
1885,  p.  336. 

50.  P.  Broca :  Trait,  de  Turn.,  vol.  ii.,  p.  272.  L.  Merner  :  De  la  Termin.  par 
Gang,  des  Corps  Fibr.  Intra-uter.,  etc.,  Paris  Thesis;  containing  an  unpublished 
case  of  Dumontpallier.  Spiegelberg  :  Archiv  f.  Gyn.,  Band  v.,  p.  100.  Riedinger  : 
Wien.  med.  Woch.,  No.  20,  1883.     Breisky  :   Zeits.  f.  Heilkunde,  Bd.  v.,  1884. 

51.  Frankenhauser  :  Correspond,  fiir  Schweiz.  Aerzte,  1875,  page  225.  Tillaux, 
Duplay,  Guyon,  Gueniot,  Polaillon  :  Bull,  de  la  Soc.  de  Chir.,  December,  1874. 

52.  Mtiller  :  Arch.  f.  Gyn.,  Bd.  vi.,  p.  127.  Chiari :  Klin,  der  Geburts.,  p.  408. 
Chrobak  :  Med.  Chir.  Rundschau,  p.  871.  P.  Walter  :  Dorpater  med.  Zeitsch..  Bd. 
iv.,  401,  1878.  J.  Browkillo  :  De  l'Extirp.  Partiel.  de  Polypes  Ut£r.  Volum.,  Paris 
Thesis,  1881;  containing  an  unpublished  case  of  Th.  Anger. 

53.  On  tamponing  of  the  uterus  after  ablation  of  tumor,  consult  Fritsch  : 
Samml.  klin.  Vortr.,  No.  288,  and  Die  Krankh.  der  Frauen,  3d  ed.,  1886,  p.  77.  On 
the  tampon  after  labor,  Diihrssen  :  Die  Uterus-Tamponade;  etc.  Centr.  fiir  Gyn.. 
Aug.  27th,  1887,  No.  35.  Auvard  :  Gaz.  hebd.,  1887,  No.  44.  Max  Kortum  :  Centr 
f.  Gyn.,  Feb.  11th,  1888.     Fraipont :  Annal.  de  la  Soc.  Med.  Chir.  de  Liege,  1888. 

54.  Bischoff :  Vortr.  in  der  med.  Gesell.  in  Basel,  Nov.  1st,  1877.  Correspond, 
f.  Schweiz.  Aerzte,  1878. 


276  CLINICAL   AND   OPEKATIVE   GYNECOLOGY. 

55.  "West :  Lecons  sur  les  Mai.  des  Femraes.  Ch.  Mauriac's  Translation,  Paris, 
1870,  p.  352. 

56.  Gillette :  Ann.  de  Gyn.,  1875,  vol.  iii.,  p.  68. 

57.  S.  Pozzi :  De  la  Valeur  de  l'Hyst^rotomie,  etc.,  1875,  p.  131. 

58.  Gusserow  :  Die  Neubildungen  des  Uterus,  1885,  p.  90. 

59.  Lomer  :  Zeits.  £.  Geb.  und  Gyn.,  Bd.  ix.,  p.  277. 

60.  Martin :  Path,  und  Ther.  der  Frauenk.,  1887,  p.  270. 

61.  Czerny  :  Wien.  med.  Woch.,  1881,  Nos.  18  and  19. 

62.  Ljocis  :  Zurich  Thesis,  1878.     Olshausen  :   Klin.  Beitr.  z.  Gyn.,  1884,  p.  96. 

63.  L.  Le  Fort :  Bull,  de  la  Soc.  de  Chir.,  July,  1888. 

64.  E.  Boeckel :   Gaz.  in6d.  de  Strasbourg,  1885,  No.  3. 

65.  St.  Sutton  :  Cited  in  Gaz.  Hebdom.,  1877,  No.  33,  and  Czerny  :  Loc.  cit. 

66.  Vanderveer  :  Boston  Med.  and  Surg.  Jour.,  Oct.,  1879. 

67.  Emmet :  Principles  and  Practice  of  Gynaecology,  3d  ed.,  London,  1885,  p. 
587.     See  especially  observation  64,  and  figs.  110  and  111. 

68.  Pean:  Gaz.  des  Hopit.,  1883,  p.  636;  ibid.,  p.  66,  1886;  ibid.,  1886,  p.  250; 
ibid.,  March  5th  and  28th,  and  April  11th,  1889.  Secheyron :  De  l'Hysterotomie 
Vaginale,  etc.     Paris  Thesis,  1888,  and  Traite  de  THyst^rectomie,  Paris,  1889. 

69.  Secheyron:  Loc.  cit.,  pp.  76  and  77,  from  which  the  description  of  the 
operation  is  taken  almost  literally. 

70.  Pean  :   Cited  by  Secheyron.     Traite"  de  l'Hyster.,  etc.,  p.  172. 

71.  Terrillon  :   Bull,  de  la  Soc.  de  Chir.,  May  15th,  1889,  p.  405     Bouilly:  Ibid. 

72.  Mikulicz :  Wien.  med.  Woch.,  1885,  No.  10. 

73.  Compare  the  figures  given  by  Hofmeier :  Grundr.  der  gyn.  Operat.,  1886, 
figs.  105  and  106,  so  analogous  as  regards  the  connection  of  the  tumor  and  represent- 
ing :  the  first,  a  fibroma  operated  on  through  the  vagina  (Hofmeier);  the  second, 
one  treated  by  abdominal  method  (Schroder) ;  success  in  both  cases. 

74.  Kottmann  :  Correspond,  f.  Schweiz.  Aerzte,  January,  1882,  No.  2,  p.  42. 

75.  Pean:  Bull,  de  l'Acad.  de  MeU,  1882.  Gaz.  des  Hop.,  Jan.,  1886.  Gomet : 
Paris  Thesis,  1886.  . 

76.  Demons  :  Revue  de  Chir.,  1884,  p.  652. 

77.  Sanger:  Arch.  f.  Gyn.,  1883,  p.  99.  Orthmann  :  Deutsche  med.  Woch.,  No. 
112.  Leopold:  Centr.  f.  Gyn.,  1888,  p.  472.  Richelot  and  Terrier:  In  A.  P.  Gavilan, 
de  l'Hysterectoniie  Vag.,  etc.  Paris  Thesis,  1888.  Spaeth  :  Centr.  f.  Gyn.,  1889, 
No.  35.     Leopold  :  Cited  by  F.  Munchmeyer.     Arch.  f.  Gyn.,  Bd.  xxvi.,  Heft  3,  1889. 

78.  Gavilan  :  page  44. 

79.  Baker  Brown:  Obst.  Trans.,  i.,  page  329,  and  iii.,  page  397. 

80.  Greenhalgh  :  Med.  Chir.  Trans.,  lix.,  page  876. 

81.  Koeberl<3:  Gaz.  m6d.  de  Strasburg,  1875,  No.  16. 


CHAPTER  XL 

TREATMENT   OF   FIBROUS   TUMORS    OF   ABDOMINAL    EVOLU- 
TION—MYOMECTOMY  AND   HYSTERECTOMY. 

Hysterectomy,  or  removal  of  fibromata  by  way  of  the  abdomen,  is 
not  an  operation  that  was  deliberately  premeditated,  but  is  the  prod- 
uct of  diagnostic  error.  After  opening  the  abdomen  to  remove  a  tumor 
presumably  ovarian,  it  has  occurred  that  the  surgeon  found  himself 
confronted  by  a  fibrous  tumor  of  the  uterus.  The  first  who  committed 
this  mistake  recoiled  from  the  terrors  of  an  unknown  operation,  and 
hastily  closed  the  abdomen  without  finishing.  These  were  the  cases 
of  Lizars  in  1825,  of  Dieff enbach  in  1826,  and  more  recently  of  Atlee 
(1849-51),  Baker  Brown,  Cutter,  Deane,  Mussey,  and  Smith.  Fourteen 
cases  of  this  kind  were  published  during  this  period,  of  which  five 
were  followed  by  death.1  Then  certain  bold  surgeons  ventured  to 
extirpate  subserous  pedicled  tumors,  Granville  in  1837  being  unsuc- 
cessful, and  the  cases  of  Atlee  and  Lane  recovering.  Clay  and  Heath 
in  1843  and  Burnham  in  1853  were  the  first  to  undertake  the  partial 
extirpation  of  the  uterus;  G.  Kimball 2  was  the  first  to  propose  hyster- 
ectomy for  an  interstitial  fibroma  which  was  the  cause  of  violent  hem- 
orrhages ;  the  patient  recovered.  Kceberle 3  was  the  second  to  do  the 
operation,  but  the  exact  determination  of  the  diagnosis,  the  rational 
choice  of  an  operative  technique,  and  the  absolute  novelty  of  the  sub- 
ject in  Europe  gave  exceptional  value  to  his  case.  The  report  which 
he  published  on  this  occasion  made  the  operation  the  fashion  of  the 
day. 

Kceberle  was  the  first  to  employ  the  metallic  loop  and  ligature- 
tightener  for  ligating  the  pedicle.  This  was  a  great  advance  over 
the  former  practice  of  tying  the  tumor  in  mass  with  thread,  a  method 
which  exposed  the  patient  to  great  risk  of  hemorrhage :  the  first  step 
was  thus  taken,  and  from  that  time  the  cases  multiplied.  In  the  year 
1866,  Caternault,  a  pupil  of  Kceberle,  published  a  series  of  forty-two 
cases  of  amputation  of  the  uterus  and  twenty  cases  of  gastrotomy  for 
the  extirpation  of  pedicled  tumors.  Many  of  the  operators  replaced 
Kceberle's  ligature-tightener  by  a  clamp,  which  they  allowed  to  re- 


278  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

main  like  a  vice  about  the  pedicle — an  inferior  method.  After  the 
operation  was  made  known,  Pean  obtained  great  success  with  it  in 
Paris  in  cases  which  were  considered  unfit  for  major  abdominal 
operations,  and  where  even  ovariotomy  appeared  bold.  The  presen- 
tation of  a  successful  case  at  the  Academy  of  Medicine  (August, 
1870),  and  three  years  later  the  publication  of  an  important  work 4 
where  the  rules  for  operation  were  established  with  a  precision  up 
to  that  time  unknown,  bound  the  name  of  Pean  5  to  hysterotomy 
with  extra-peritoneal  treatment  of  the  pedicle.  The  technique  con- 
sisted chiefly  in  the  employment  of  f orcipressure,  which  Kceberle  was 
the  only  one  to  use  freely  at  that  time;  in  fractional  excision  of  large 
tumors,  after  the  application  of  a  metallic  ligature,  to  avoid  opening 
the  abdomen  too  freely;  and  in  transfixing  the  pedicle  with  sharp 
needles  placed  crosswise  below  a  steel- wire  ligature  applied  by  Cin- 
trat's  ingenious  tightener.  This  technique,  of  which  the  latest  im- 
provements have  still  retained  the  general  features,  was  for  a  long 
time  adopted  by  all  operators  in  France  and  elsewhere.  It  is,  then, 
to  these  two  French  surgeons  that  the  merit  belongs  of  having  estab- 
lished the  operation  upon  a  scientific  basis.6 

After  this  first  stage  in  the  progress  of  abdominal  hysterotomy, 
marked  by  metallic  constriction  of  the  pedicle,  and  followed  by  many 
arguments  and  disputes,7  there  was  a  second  stage  characterized  by 
the  application  of  antisepsis  to  the  operation  as  to  all  others  in 
surgery. 

Finally,  a  third  phase  was  inaugurated  by  perfection  of  the  tech- 
nique, and  especially  by  the  introduction  of  the  elastic  ligature  for 
temporary  or  final  hsemostasis.8  The  most  marked  feature  of  the  time 
was  the  strife  between  partisans  of  extra-peritoneal  and  intra-peri- 
toneal  methods,  and  the  substitution  of  castration  for  hysterotomy  in 
a  large  number  of  cases. 

Synonyms. — The  term  hysterotomy,  wmich  means,  from  its  ety- 
mology, section  of  the  uterus,  is  essentially  comprehensive ;  wuth  the 
adjective  abdominal,  it  may  be  applied  to  every  operation  where  the 
uterine  tissue  is  removed  after  opening  the  abdomen.  Still  another 
word  may  be  employed  for  the  sake  of  precision;  thus,  supra- vaginal 
hysterotomy  means  section  or  ablation  of  the  uterus  above  the  vagina. 
Tillaux,  in  a  communication  to  the  Academie  in  1889,  proposed  the 
word  hysterectomy,  which  conveys  the  idea  of  excision,  for  those  cases 
where  a  part  or  the  whole  of  the  organ  is  removed.  This  more  exact 
term  has  rapidly  prevailed,  although  the  older  form  is  still  met  with. 


TREATMENT  OF  FIBROUS  TUMORS  OF  ABDOMINAL  EVOLUTION.     279 

The  Germans  employ  the  word  myomotomy  or  myomectomy  for  re- 
moval of  a  myoma  with  all  or  a  part  of  the  uterus,  thus  including 
both  hysterotomy  for  pedicled  fibroma  and  partial  hysterectomy  for 
interstitial  fibroma.  Lastly,  by  intra-peritoneal  enucleation  is  meant 
simply  incision  into  the  uterine  wall  to  remove  a  tumor,  with  pre- 
servation of  the  uterus  itself. 

General  Indications  for  Abdominal  Hysterectomy.  — We  shall 
see  further  on  that  the  possibility  of  substituting  for  this  always 
serious  operation  another  which  is  less  grave,  namely,  castration,  re- 
duces in  certain  definite  circumstances  the  field  of  hysterectomy. 
We  may  thus  formulate  the  indications  for  the  operation: 

Rapid  growth  of  the  tumor;  grave  hemorrhage  which  does  not 
yield  to  any  palliative ;  ascites  produced  by  the  irritation  of  a  very 
movable  fibroma ;  compression  of  important  organs ;  very  large  tumor, 
and  especially  its  cystic,  cedematous,  or  suppurative  degeneration; 
symptomatic  prolapsus  of  the  uterus ;  pregnancy,  when  the  fibroma 
will  manifestly  be  a  serious  cause  of  dystocia. 

The  classification  which  may  be  established  for  the  abdominal 
operation  is  as  follows: 

I.  Pedicled  fibroma. 

II.  Fibroma  with  a  single  nucleus. 

III.  Fibroma  with  many  nuclei. 

IV.  Fibroma  within  the  pelvis  or  the  ligaments. 

In  the  first  class  the  removal  of  the  tumor  is  extremely  simple 
and  differs  but  little  froni  ovariotomy;  it  is  here  only  that  the  term 
myomectomy  is  applicable. 

For  the  second  and  third  varieties  we  may  generally  perform  par- 
tial hysterotomy  or  supra-vaginal  hysterectomy,  according  to  the  loca 
tion  of  the  tumor ;  in  certain  special  cases  we  may  practise  intra-peri- 
toneal enucleation. 

In  the  fourth  class,  if  it  is  not  possible  to  employ  the  palliative 
operation  of  castration,  we  should  attempt  an  intra-ligamentous 
decortication. 

Finally,  total  extirpation  of  the  organ  by  the  abdominal  method 
has  been  practised  for  certain  multiple  tumors  which  involved  the 
cervix,  with  hypertrophy  of  the  tissues  and  no  opportunity  of  saving 
a  pedicle. 

Before  passing  these  different  operations  and  'their  varieties  in 
review,  I  wish  to  say  a  few  words  concerning  an  operative  manoeuvre 
wThich  is  applicable  to  them  all,  and  which  has  completely  changed 


280  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

their  technical  conditions  since  its  introduction  into  abdominal 
surgery. 

Provisional  Hcemostasis  during  the  Operation  of  Hysterotomy. 
— Whatever  may  be  the  nature  of  the  operation  done  in  the  abdomi- 
nal cavity,  it  is  of  the  greatest  importance  to  be  able  to  perform  it 
without  much  bleeding.  To  obtain  this  end  the  older  operators 
employed  the  compression  of  the  ecraseur;  Billroth  invented  an  enor- 
mous forceps  which  might  be  used  in  such  cases  (Fig.  48,  p.  67).  A 
most  valuable  means  of  controlling  the  hemorrhage  is  the  temporary 
elastic  ligature,  which  must  not  be  confounded  with  the  permanent 
ligature  to  be  described  further  ou.  Kleeberg,9  of  Odessa,  first  used 
the  elasticity  and  steadiness  of  rubber  to  procure  a  constant  constric- 
tion of  the  uterine  pedicle.  He  replaced  the  metallic  ligature  of 
Kceberle  and  Pean  with  an  elastic  tube,  leaving  it  in  place  perma- 
nently, and  the  patient  was  cured.  But  it  was  Hegar  who  raised  it 
to  its  present  rank,  and  Martin 10  who  gave  a  general  application  to 
the  procedure,  so  that  it  now  fills  in  gynaecological  practice  the  place 
of  Esmarch's  bandage  in  general  surgery. 

For  the  permanent  elastic  ligature  a  thick  rubber  tube  of  about  5 
mm.  diameter  is  employed  in  Germany.  I  prefer  a  solid  cord  of  the 
same  size,  and,  after  my  communication  which  made  it  known,  it  has 
L^en  generally  adopted  in  France.11  It  has  the  advantage  of  being 
more  easily  sterilized  and,  with  the  same  volume,  is  more  resistant. 
The  temporary  ligation  is  best  obtained  by  the  same  elastic  cord. 
After  stretching  It  and  making  two  or  three  turns  round  the  part,  the 
crossed  ends  are  secured  by  a  strong  pressure  forceps ;  for  this  pur- 
pose Hegar  has  a  special  form  of  forceps,  with  short-elbowed  jaws 
which  are  quite  convenient.  I  have  invented  an  elastic  constrictor 
which  renders  good  service  when  the  surgeon  is  obliged  to  work  in  a 
narrow  cavity,  and  which  is  far  less  cumbrous  than  forceps.  Certain 
operators,  forgetting  the  real  object  of  this  instrument,  have  used  it 
for  the  purpose  of  permanently  securing  the  ligature,  but  this  end  is 
best  attained  by  a  double  thread  of  silk ;  the  ligator  being  only  em- 
ployed for  tightening  the  rubber  cord.  (For  the  technique  see  p.  53 
and  Fig.  44,  p.  62.) 

I.  Pedicled  Fibroma — Myomectomy. — After  the  provisional  liga- 
ture has  been  applied  as  low  down  on  the  uterus  as  possible,  the 
pedicle,  if  thin,  is  pierced  with  a  needle  armed  with  double  silk,  whose 
ends  are  secured  by  Bantock's  or  Tait's  knot  (Fig.  34,  No.  5  and  6, 
p.  54).     If  the  operator  is  not  familiar  with  this  special  knot,  he  sim- 


TREATMENT  OF  FIBROUS  TUMORS  OF  ABDOMINAL  EVOLUTION.     281 

ply  cuts  the  loop  and  ties  the  ends  right  and  left  after  crossing  them 
by  a  half -turn  (Fig.  34,  3  and  4) ;  to  make  the  surgical  knot,  the 
thread  must  always  be  passed  twice  (Fig.  34,  2). 

If  the  pedicle  is  thick,  it  is  well  to  seize  and  compress  it  with 
Billroth's  clamp-forceps  (Fig.  48,  p.  67)  while  the  tumor  is  cut  trans- 
versely, taking  care  to  leave  a  collar  of  peritoneum  and  capsule 
about  the  margin  of  the  wound.  The  clamp  is  then  removed,  and  in 
the  furrow  which  it  has  traced  around  the  foot  of  the  pedicle  a  series 
of  silk  sutures  are  placed.  The  excess  of  tissue  left  above  the  seat  of 
the  clamp  is  then  cut  away,  leaving  only  enough  to  cover  the  wounded 
surface,  that  being  secured  by  the  sutures  already  passed  and  a  few 
superficial  points.  The  provisional  elastic  ligature  is  then  removed, 
and  if  there  is  much  oozing  by  the  sutures  a  few  deeper  ones  are 


Fig.  150. — Suture  of  the  Thin  Fold  of  Peritoneum  and  Fibrous  Tissue  Left  after  the  Detach- 
ment of  a  Firm  Adhesion.    7,  Intestine;  P,  peritoneal  fold  covering  the  fibroid;  S,  suture. 

added.  If,  at  the  moment  of  section,  it  is  possible  to  see  any  of  the 
large  vessels,  they  are  separately  tied. 

The  pedicle  is  returned  to  the  cavity  of  the  abdomen  only  when 
all  oozing  is  completely  arrested;  if  there  is  still  any  fear  of  further 
bleeding,  tamponing  of  the  pedicle  is  practised  by  the  method  of 
Woltler-Hacker  described  below.  With  large  pedicled  fibromata  wide 
adhesions  to  the  intestines  may  be  found  with  adventitious  vascular 
connections  more  important  than  those  of  the  pedicle  itself.  To  de- 
tach these  adhesions  when  they  are  intimate  we  make  use  of  the  pro- 
cedure recommended  by  Schroder,  leaving  adherent  to  the  intestine 
a  superficial  portion  of  the  fibroma  with  its  peritoneum,  and  rjassing 
one  or  more  catgut  sutures  so  as  to  secure  the  coaxvtation  of  the  bleed- 
ing surface  (Fig.  150). 

II.  Bncapsulecl  Fibroma,  with  one  Nucleus.  Irttra-peritoneal 
Enucleation. — Cases  of  this  variety  are  relatively  rare,  the  most  com- 


282 


CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 


mon  form  being  multiple  fibromata,  distorting  a  large  segment  of  the 
uterus,  which  seems  to  be  stuffed  full  of  them  (Figs.  130,  131,  p.  218). 
To  treat  each  one  of  these  nuclei  separately  would  not  be  possible,  but 
when  the  tumor  is  single,  whether  formed  by  a  simple  or  a  compound 
mass,  whether  interstitial  or  submucous,  it  is  possible  to  carry  out  the 
plan  of  removal  by  enucleation  of  the  neoplasm  alone,  preserving  the 
integrity  of  the  uterus  and  its  adnexa,  and  not  interrupting  the  geni- 
tal life  of  the  woman.  This  consideration  will  have  some  weight  when 
the  patient  is  not  near  the  menopause,  but  it  rarely  needs  to  be-con- 


Fig.  151. — A,  Enucleation  of  an  Interstitial  Myoma;  B,  Disposition  of  Sutures  after  Enucleation. 

sidered.  Enucleation,  then,  may  often  be  considered  only  a  simplifi- 
cation of  the  operative  technique  applicable  to  certain  definite  cases. 

Spiegelberg 12  seems  to  be  the  first  who  employed  it;  Spencer 
Wells13  has  practised  it  for  a  long  while;  but  it  is  A.  Martin14  who 
has  especially  advocated  it. 

We  begin  by  drawing  the  uterus  outside  of  the  abdomen  upon  a 
layer  of  gauze  sponge,  and  placing  about  the  cervix  an  elastic  cord 
with  its  ends  crossed  and  held  in  place  by  forceps  or  my  ligator. 
Having  thus  provided  for  control  of  the  bleeding,  the  uterus  is  incised 
over  the  most  projecting  part  of  the  tumor,  and  this  is  removed,  care 
being  taken  not  to  open  the  uterine  cavity. 

As  this  operation  has  often  been  performed  for  submucous  fibroma, 
which  most  surgeons  prefer  to  remove  by  the  vagina,  the  uterine 
canal  has  sometimes  been  opened  (10  cases  out  of  16:    Martin);  in 


TREATMENT  OF  FIBROUS  TUMORS  OF  ABDOMINAL  EVOLUTION.     283 

these  cases  Martin  closed  the  mucous  wound  with  a  continuous  cat- 
gut suture. 

The  incision  in  the  uterine  wall  is  closed  by  a  series  of  deep  sutures 
taking  in  the  whole  extent  of  the  wound.  Martin  uses  for  this  pur- 
pose catgut  prepared  in  oil  of  juniper,  which  he  has  substituted  for 
carbolized  silk  (Fig.  151). 

When  the  cavity  left  after  the  removal  of  the  tumor  is  very  large, 
Martin  uses  a  cross-drain  passed  through  the  cervix  into  the  vagina. 
Freund,15  in  a  remarkable  case  which  was  followed  by  success,  where 
the  fibroma  was  inflamed,  replaced  the  rubber  drain  by  an  iodoform- 
ized  wick,  and  then  tamponed  the  uterus  with  iodoform  gauze.  We 
may  also  diminish  the  tumor  cavity  by  removing  portions  of  its  wall. 

Martin,  in  one  case,  also  removed  both  the  degenerated  ovaries,  and 
once  a  single  ovary.  He  recommends  castration  in  all  cases  where 
we  suspect  the  presence  in  the  uterine  tissue  of  another  fibrous 
nodule  beyond  our  reach. 

In  sixteen  cases  he  had  three  deaths ;  and  once  he  had  to  do  a 
secondary  vaginal  amputation  of  the  uterus  because  of  the  appear- 
ance of  a  new  fibroma  whose  origin  had  been  unforeseen  at  the  time 
of  the  first  operation.  The  possibility  of  this  second  operation  is  the 
weak  point  in  the  whole  method,  and  for  that  reason  it  should  always 
be  combined  with  castration.  In  this  case,  however,  enucleation  fails 
of  its  initial  object,  which  is  to  maintain  the  genital  functions,  and 
becomes  simruy  a  particular  case  of  partial  hysterectomy  with  tne 
pedicle  left  within  the  peritoneum. 

III.  Fibroma  with  Multiple  Nuclei.  Supra-vaginal  Hysterec- 
tomy.— According  to  Schroder  we  must  distinguish  two  different 
classes ;  the  first,  where  the  tumor  is  above  the  adnexa  at  its  lower 
level,  the  body  of  the  uterus  being  intact;  and  the  second  where  the 
body  is  invaded  in  snch  a  way  that  the  adnexa  form  a  more  or  less 
sessile  ajypendix  to  the  tumor. 

In  the  first  class  the  rule  is  not  to  detach  the  broad  ligaments, 
which  would  render  the  operation  more  serious ;  but  as  we  are  never 
sure  that  there  are  no  small  nodules  remaining  in  the  uterus  which 
may  develop  later,  it  is  prudent  to  remove  the  ovaries  as  the  last  step. 
In  this  way  we  do  not  usually  obtain  as  narrow  a  pedicle  as  by 
complete  ablation  of  the  body  of  the  uterus,  which  will  be  reason 
enough  to  reject  partial  hysterectomy;  it  is  possible,  however,  to  do 
the  operation  without  opening  the  uterine  cavity  which  diminishes 
the  chances  of  infection. 


284  CLINICAL  AND   OPERATIVE   GYNAECOLOGY. 

Partial  hysterectomy  presents  no  essential  difference  from  supra- 
vaginal amputation,  with  the  exception  that  it  does  not  include  the 
detachment  of  the  broad  ligament.  The  temporary  elastic  ligature  is 
placed  below  the  tumor,  which  is  removed  with  its  capsule,  saving 
only  a  portion  of  the  latter  to  make,  with  the  peritoneum  and  sub- 
serous tissues,  a  collar  about  the  wound.  This  operation  is  distin- 
guished from  enucleation  by  the  removal  of  the  mass  as  a  whole,  and 
by  excising  it  with  the  knife;  I  advise  that  the  operator  should 
always  assure  himself  beforehand  by  a  vertical  cut  that  enucleation 
is  not  possible;  for  when  it  is,  it  is  preferable. 

Supra- vaginal  amputation,  or  hysterectomy,  is  a  typical  operation, 
which  we  adopt  in  the  majority  of  cases,  either  at  once  or  after 
trying  enucleation  or  partial  hysterectomy.  Two  methods  divide  the 
preferences  of  surgeons ;  the  first,  where  the  pedicle  is  treated  exterior 
to  the  peritoneum,  to  which  are  attached  the  names  of  Kceberle,  Pean, 
and  Hegar;  the  second,  the  method  where  the  pedicle  is  abandoned 
within  the  peritoneum,  or  Schroder's  ojDeration,  which  has  been  mod- 
ified by  many  different  authors.  Lastly,  I  shall  describe  a  procedure 
which  unites  the  advantages  of  both  the  preceding  with  ablation  of 
both  uterus  and  cervix,  or  the  mixed  method  of  total  hysterectomy. 

Technique  of  Supra-vaginal  Hysterectomy. — The  first  steps  of 
the  operation  are  identical  whether  Hegar's  or  Schroder's  operations 
are  performed.  The  abdomen  is  rapidly  opened  through  the  linea 
alba  without  stopping  to  put  forceps  upon  the  little  bleeding  points. 
If  the  tumor  is  small  and  chiefly  within  the  lower  pelvis,  the  incision 
is  prolonged  nearly  to  the  pubes,  but  with  the  precaution  of  keeping 
a  sound  in  the  bladder.  We  have  always  reason  to  fear  a  wound  of 
this  organ  from  elongation  of  it  in  front  of  the  tumor.16  To  give  a 
little  more  room  below,  the  muscular  insertion  on  one  side  or  the 
other  may  be  divided,  though  I  do  not  advise  it. 

If  the  tumor  is  very  large  and  soft,  we  should  see  whether  it  may 
be  diminished  by  puncture  of  a  cystic  cavity;  if  not,  it  is  better  to 
prolong  the  incision  to  the  xiphoid  cartilage,  if  necessary,  rather  than 
to  attempt  the  long,  difficult,  and  perilous  procedure  of  fractional  ex- 
cision advocated  by  Pean.17 

The  uterus  must  then  be  disengaged  so  that  the  elastic  ligature 
may  be  put  in  place,  the  connections  of  the  bladder  with  the  tumor 
having  been  determined  by  exploration  with  a  male  sound.  It  has 
happened  to  good  surgeons  that  a  portion  of  the  bladder  has  been 
included  in  the  ligature  and  removed.     To  avoid  such  an  accident  in 


TREATMENT  OF  FIBROUS  TUMORS  OF  ABDOMINAL  EVOLUTION.     285 

difficult  cases  Albert  transfixes  the  tumor  immediately  above  the 
bladder  with  a  pin  to  prevent  the  ligature  from  slipping  and  includ- 
ing part  of  it. 

The  broad  ligaments  are  cut  between  a  double  series  of  ligatures 
which  are  passed  by  a  blunt,  mounted  needle  (Fig.  19,  2  to  3)  either 
straight  and  curved  a  little  at  the  point  or  similar  in  form  to  a  Des- 
champs  needle  (for  technique  see  pages  53  to  65) ;  the  tube  and  round 
ligaments  should  be  separately  tied.  As  soon  as  the  upper  part  of 
the  cervix  is  free,  the  elastic  ligature  is  put  in  place.  Some  authors 
advise  to  go  immediately  below  and  search  for  the  uterine  arteries  by 
feeling  their  pulsation  or  their  projection  upon  the  sides  of  the 
uterus.  For  this  purpose  it  is  necessary  to  descend  to  the  folds  of 
Douglas  which  bound  the  cul-de-sac  of  that  name,  including  a  certain 


Fig.  152.— Chain  Ligature. 


portion  of  the  adjacent  soft  tissues  within  the  ligature.  One  of  the 
great  advantages  of  the  extra-peritoneal  method  is  that  it  dispenses 
with  this  dangerous  step. 

It  is  always  better  to  remove  the  adnexa,  though  certain  operators 
attach  but  little  importance  to  neglect  of  this  extirpation,  thinking 
that  the  tissues  will  atrophy.  Where  there  are  no  difficulties  caused 
by  extensive  adhesions,  castration  should  be  performed  at  the  same 
time,  on  account  of  the  accidents  which  have  been  described,  such  as 
pelvic  hematocele  (Pean,  Kceberle)  and  extra-uterine  pregnancy 
(Kceberle).18  When  the  uterus  is  sufficiently  freed  from  its  peripheral 
attachments,  the  elastic  ligature  is  applied  to  the  cervix,  and  then  an 
anteroposterior  incision  made  a  finger's  breadth  above  it,  and  the 
fibroma  removed  as  soon  as  possible  by  section  and  enucleation.  From 
this  moment,  according  to  the  treatment  of  the  pedicle  the  operation 
varies. 

Intra-peritoneal  Treatment,  of  the  Pedicle. — I  will  describe 
Schroder's  technique  as  it  is  given  by  Hofmeier.19    In  proceeding 


286 


CLINICAL   A1STD   OPERATIVE   GYNAECOLOGY. 


with,  the  removal  of  the  tumor  we  should  be  careful  to  finish  by  a 
circular  conoidal  incision  at  least  3  cm.  from  the  ligature  and  not 
going  more  deeply  beneath  the  peritoneum  than  to  slightly  pare  off 
this  membrane,  so  that  the  rim  of  tissue  left  is  partly  serous ;  with 
the  scissors  it  is  then  trimmed  so  that  with  slight  traction  it  just  covers 
the  whole  of  the  wound;  all  gaping  vessels  that  may  be  found  are 
tied  with  catgut. 

An  important  feature  of  the  operation  is  the  destruction  and  disin- 
fection of  the  mucous  membrane  of  the  uterine  cavity,  which  is  found 
in  the  bottom  of  the  wound.     There  is  no  doubt  that  this  opening  of 


Fig.  153.— Schroeder's  Intra-peritoneal,  Suture  of  the  Pedicle.  S,  Deep  suture,  passed  at  once 
Tinder  the  whole  bleeding  surface;  C,  continuous  suture  of  catgut  in  different  terraces,  bringing  together 
the  whole  wounded  surface  whose  lower  portion  is  marked  by  the  heavy  hue  aa,  formed  by  the  cauterized 
uterine  cavity;  P,  peritoneal  investment. 

the  uterus  forms  one  of  the  unfavorable  elements  in  the  intra-peri- 
toneal  treatment,  since  it  may  be  a  source  of  infection ;  though  certain 
authors,  as  Martin,  for  examine,20  ascribe  but  little  importance  to  it. 
But  Hofmeier,  in  his  analysis  of  Schroder's  operations,  has  clearly 
demonstrated  this  influence  (21  cases  without  opening,  2  deaths; 
59  with  opening,  18  deaths).531  It  is  important,  then,  to  reduce  this 
danger  to  a  minimum  both  by  securing  rapid  cicatrization  by  exact 
coaptation  and  by  completely  modifying  the  membrane  adjacent 
to  the  wound.  For  this  purpose  Olshausen 22  recommends  the  free 
excision  of  the  bottom  of  the  wound  in  the  shape  of  a  funnel,  dissect- 
ing out  as  much  as  possible  of  the  mucous  membrane.  It  is  well  also 


TREATMENT  OF  FIBROUS  TUMORS  OF  ABDOMINAL  EVOLUTION.     287 


to  cauterize  the  bottom  of  the  wound  with  strong  carbolic  acid  (1 :  10), 
or  better  with  the  Paquelin  therm  o-cautery,  which  should  be  buried 
perpendicularly  in  the  cervical  canal.  We  must  not,  however,  cau- 
terize the  superficial  portions  of  the  wound  for  fear  of  preventing 
primary  union. 

The  next  step  consists  in  the  application  of  the  suture.  Veit  and 
Martin  employ  juniper  catgut;  Schroder  and  Hofmeier  use  both 
catgut  and  silk.  If  the  bleeding  surface  is  not  extensive,  it  is 
sufficient  to  pass  deep  sutures  with  a  strong  needle  under  the  whole 


Fig.  154. — Vaginal,  Drainage  with  a  Cross  Tube  after  Abdominal,  Hysterectomy  (Martin). 


wounded  surface,  forming  thus  a  series  of  separate  points,  which  are 
firmly  tied,  and  completing  the  junction  of  the  peritoneum  by  a  super- 
ficial suture.  It  must  always  be  kept  in  mind  that  exact  coaptation 
is  indispensable  for  complete  primary  union ;  the  difficulty  is  to  tie 
tightly  enough  to  obtain  it  without  compromising  the  nutrition  of 
the  tissues. 

If  the  wounded  surface  is  extensive,  perfect  union  of  the  sides  is 
obtained  by  the  employment  of  the'  continuous  catgut  suture  in 
tiers,  or  with  separate  silk  sutures,  which  Schroder  originally  used. 
For  fear,  however,  that  the  catgut  will  be  too  quickly  absorbed, 
especially  if  the  tissues  are  very  dense,  certain  sustaining  sutures 


288  CLINICAL   AND   OPERATIVE   GYNECOLOGY. 

of  silk  are  placed  at  equal  distances  through  the  whole  thickness  of 
the  wound  before  beginning  the  continuous  suture.  These  are  tied 
after  the  continuous  suture  is  finished,  but  they  are  put  in  position 
beforehand  in  order  not  to  cut  the  catgut  in  passing  them.  They 
should  be  inserted  a  little  obliquely,  and  not  perpendicular  to  the  axis 
of  the  wound,  that  they  may  not  be  parallel  to  the  vessels  which 
they  are  meant  to  constrict  (Fig.  153,  Hofmeier).  The  wound  should 
be  closed  longitudinally,  that  is,  parallel  with  the  abdominal  opening 
(Gersuny,  Fritsch,  etc.). 

When  the  suture  of  the  pedicle  has  been  completed  by  Schroder's 
method,  if  a  few  drops  of  blood  ooze  by  the  side  of  the  suture,  after 
the  elastic  band  has  been  removed,  Martin 23  does  not  hesitate  to  pass 
through  the  pedicle  from  before  backward  a  strong  needle  with  quad- 
ruple thread,  and  thus  tie  it  in  two  portions ;  in  autopsies  which  he 
has  had  occasion  to  make,  he  has  never  seen  any  trace  of  mortification 
from  this  complementary  ligature,  which  Leopold  also  employs  at 
times. 

After  hysterectomy,  no  matter  how  simple  the  operation  has  been, 
Martin  always  practises  drainage  through  the  vagina  (p.  71).  The 
lower  end  of  the  tube  is  always  folded  in  the  vagina  and  covered  with 
antiseptic  gauze  to  prevent  the  entrance  of  germs  from  the  air ;  it  is 
withdrawn  on  the  third  or  fourth  day,  when  the  patient  begins  to  feel 
a  peculiar  uneasiness  in  the  lower  part  of  the  abdomen  (Fig.  154). 
This  drainage,  after  simple  operations,  without  destruction  of  the 
peritoneum  or  septic  infection,  is  not  generally  employed,  and  seems 
to  me  unnecessary. 

Extra-peritoneal  Treatment  of  the  Pedicle — Hegar's  Method. — 
The  abdominal  cavity  is  closed  as  tightly  as  possible  about  the  tumor, 
and  this  is  surrounded  by  gauze-sponges  to  receive  the  blood ;  the 
incision  is  then  made  transversely,  two  fingers  breadth  above  the  elastic 
ligature.  At  this  moment  the  fibrous  nodules  which  penetrate  the 
pedicle  appear  upon  the  cut  surface ;  they  may  be  enucleated  with- 
out danger  of  bleeding,  the  elastic  band  compressing  the  pocket 
left  empty  by  the  small  tumor.  Bleeding  vessels  should  be  sepa- 
rately tied.  The  surface  of  the  stump  is  then  smoothed  and  held 
strongly  drawn  out  with  Museux  forceps.  We  then  proceed  with 
the  toilet  of  the  peritoneum,  keeping  the  pedicle  fixed  in  the  lower 
part  of  the  wound.  The  temporary  elastic  ligature  may  often  be  per- 
manently retained  if  it  is  properly  placed,  but,  if  too  far  down  to  per- 
mit the  drawing  out  of  the  pedicle,  a  new  one  is  placed  above  it  and 


TREATMENT  OF  FIBROUS  TUMORS  OF  ABDOMINAL  EVOLUTION.     289 

tied  before  the  first  is  removed.  When  the  pedicle  is  very  large,  it  is 
well,  according  to  Hegar,  to  tie  it  in  two  portions  after  transfixing  it 
with  a  doable  elastic  band  by  means  of  a  special  instrument,  Kalten- 
bach's  needle.24  This  complication,  it  seems  to  me,  might  be  avoided 
by  taking  an  additional  turn  of  the  elastic  ligature  as  TaurTer  has 
lately  advised.25 

In  applying  the  permanent  ligature,  the  greatest  care  must  be 
taken  to  avoid  the  inclusion  of  intestinal  coils  or  bladder  and  to  see 
that  nothing  but  the  pedicle  is  constricted.26  It  is  applied  in  the  fol- 
lowing manner:  While  an  assistant  holds  the  pedicle  in  place  with 
the  Museux  forceps,  we  make  two  turns  about  it  with  the  elastic  cord 
in  such  a  way  that  it  is  tightly  constricted.  The  ends  are  crossed 
and  the  cord  stretched  a  little.  Between  the  cross  and  the  cervix 
a  ligature  of  strong  silk  is  applied  with  the  double  surgical  knot 
(Fig.  34,  2) ;  then,  after  gentle  traction  on  the  instrument  to  stretch 
the  elastic  cord  a  little  more  and  give  room,  a  second  ligature  is  ap- 
plied for  security  a  few  millimetres  in  front  of  the  first.  After  re- 
moving the  forceps  or  the  clamp  (Figs.  41  and  44),  the  ends  of  the  silk 
are  then  cut  short,  leaving  those  on  the  elastic  cord  a  little  the  longer. 

One  of  the  most  important  points  in  Hegar's  method  is  the  com- 
plete isolation  of  the  pedicle  outside  of  the  abdominal  cavity.  By  sutur- 
ing the  peritoneum  below  the  elastic  ligature  and  by  non-suture  of  the 
immediately  adjacent  abdominal  planes  he  forms  a  gutter  which  sur- 
rounds the  pedicle  so  that  it  remains  isolated  like  a  pistil  in  the  centre 
of  a  flower.  This  gutter  prevents  the  pedicle,  which  is  meant  to 
slough  off,  from  being  imprisoned  within  the  soft  parts  and  infecting 
them,  and  about  it  we  can  make  topical  applications  destined  to  mum- 
mify it  and  keep  it  aseptic.  It  is  especially  in  very  stout  patients 
that  this  peculiarity  of  the  technique  is  of  the  greatest  value. 

To  suture  the  peritoneum  about  the  pedicle,  Tauffer  fixes  in  the 
lower  part  of  the  abdominal  incision  a  long  thread  with  two  ends ; 
each  is  provided  with  a  needle,  and  is  used  to  attach  the  peritoneum 
to  the  surface  of  the  pedicle  immediately  below  the  ligature,  right 
and  left;  I  prefer  to  accomplish  this  with  catgut  and  a  single  needle 
(Plate  VI.,  Figs.  1  and  2). 

Great  care  must  be  taken  that  only  the  serous  surface  is  included 
in  this  suture,  using  a  very  fine  curved  needle  that  the  punctures 
may  not  bleed.  It  is  well  in  the  same  suture  to  attach  the  stump  of 
the  broad  ligament  on  each  side  to  the  stump  of  the  uterus  as  closely 
as  .possible.    When  this  peritoneal  collar  has  been  applied  to  the 

19 


EXPLANATION   OF  PLATE  VI. 

Extra-peritoneal   Treatment   of  the  Pedicle  After 
Supra-vaginal  Hysterectomy  (Hegar's  Method). 

Pig.  1. — The  suture  of  the  peritoneum  to  the  lower  part  of  the 
pedicle  is  begun ;  the  pedicle  being  strongly  drawn  upward 
so  that  its  distance  from  the  pubes  is  much  increased. 

Pig.  2. — Suture  of  peritoneum  about  lower  portion  of  the  pedicle 
completed. 

Pigs.  3  and  4. — Suture  of  abdominal  walls  above  the  pedicle. 
(3)  Continuous  catgut  suture  of  the  peritoneum,  and  (4)  of 
the  musculo-aponeurotic  planes. 

Pig.  5. — Peritoneum  sutured  in  a  ring  about  the  lower  part  of 
the  pedicle;  the  stump  being  strongly  depressed  to  show 
this  suture.  Deep  sutures  for  integument  in  place  and  su- 
perficial ones  tied  above  the  pedicle. 

For  the  purpose  of  demonstrating  the  arrangement  and 
to  allow  movement  of  the  stump,  the  wound  is  shown  with 
the  cutaneous  sutures  below  the  pedicle  not  yet  in  place. 


TREATMENT  OF  FIBROUS  TUMORS  OF  ABDOMINAL  EVOLUTION.     291 

pedicle,  we  may  continue  the  suture  of  the  peritoneum  through  the 
whole  length  of  the  abdominal  opening  with  the  same  needle  and 
catgut,  adding,  if  necessary,  a  few  supplementary  points.  The  suture 
of  the  other  abdominal  planes  is  begun  about  4  cm.  above  the  pedicle 
(Plate  VI.,  Figs.  3  and  4). 

To  prevent  the  pedicle  from  descending  too  far  into  the  pelvis 
under  the  influence  of  movement,  etc.,  two  strong  pins,  crossing  like 
the  letter  X>  are  passed  through  just  above  the  ligature,  and  their 
pointed  ends  cut  off.  These  pins  have  the  additional  advantage  of  pre- 
venting the  elastic  ligature  from  slipping.  Below  their  ends  small 
pads  of  iodoform  gauze  are  placed  to  prevent  their  wounding  the 
integument  (Plate  VI.,  Fig.  5).  Then,  with  the  scissors,  the  pedicle 
is  trimmed  to  the  shape  in  which  it  is  to  be  left,  and  after  sur- 
rounding it  with  wet  antiserjtic  compresses  its  surface  is  cauterized 
with  the  thermo-cautery. 

Hegar,  Kaltenbach,  and  Tauffer  dress  the  wound  as  follows:  A 
tampon  of  cotton  moistened  with  a  solution  of  zinc  chloride  (1 :  2)  is 
placed  over  the  centre  of  the  pedicle,  which  is  surrounded  with  cotton 
which  has  been  dipped  in  a  zinc  solution  (1:10)  and  carefully  squeezed 
dry.  Over  and  about  this  is  placed  iodoform  gauze  covered  with  sev- 
eral layers  of  cotton  and  held  in  place  by  a  flannel  body-bandage. 
This  first  dressing  is  usually  left  in  place  for  from  five  days  to  a  week, 
and  is  then  found  dry  and  hard.  The  tampons  of  zinc  cotton  about 
the  pedicle  are  now  replaced  by  iodoform  gauze  and  the  pedicle  itself 
is  touched  anew  with  the  caustic  solution  to  mummify  the  eschar  and 
prevent  its  becoming  soft  and  fetid.  This  dressing  is  repeated  every 
day,  and  if  the  pedicle  is  very  large  the  mortified  parts  are  removed 
little  by  little  with  the  scissors. 

Kaltenbach 27  has  recently  substituted  for  the  chloride  of  zinc,  which 
has  the  disadvantage  of  making  too  extensive  an  eschar  and  giving 
rise  to  capillary  bleeding,  a  dressing  of  iodoform  gauze ;  but  in  very 
fat  or  very  anaemic  patients  this  exj)oses  to  the  risk  of  poisoning  from 
rapid  absorption  in  the  deep  gutter  Avhich  surrounds  the  pedicle. 
Kaltenbach  and  Hegar  have  had  good  results  with  the  mixture  of  three 
parts  tannin  and  one  part  salicylic  acid  which  Freund  recommends  for 
use  after  operation  in  extra-uterine  pregnancy;  I  substitute,  for  the 
salicylic  acid,  iodoform  in  the  proportion  of  1:5  of  the  tannin,  and 
find  the  mixture  very  serviceable.  After  the  operation,  as  soon  as  the 
interior  of  the  pedicle  has  been  cauterized,  the  gutter  about  the  pedi- 
cle is  filled  with  the  powder,  and  then  the  dressings  applied ;  thus 


292  CLINICAL   AND   OPEEATIVE   GYNAECOLOGY. 

the  part  is  tanned,  so  to  speak,  witli  no  danger  of  cauterizing  the  ad- 
jacent healthy,  tissue.  The  first  dressing  is  left  in  place  from  eight  to 
ten  days. 

This  modification  is  a  great  improvement,  permitting  the  patient 
to  rest  quietly  instead  of  fatiguing  her  with  repeated  dressings,  and 
producing  the  drying  up  of  the  entire  pedicle,  without  the  need  of 
removing  portions  of  it  from  time  to  time  with  the  scissors. 

On  the  third  or  fourth  day  after  the  operation  it  is  not  uncommon 
to  see,  as  after  salpingectomy,  a  slight  sanguineous  discharge  from  the 
vagina ;  this  is  of  no  serious  importance. 

The  elastic  ligature  and  the  pedicle  with  its  pins  usually  fall  on 
the  fifteenth  to  twentieth  day,  leaving  a  granulating  funnel  which 
should  be  lightly  packed  with  iodoform  gauze ;  it  is  sometimes  very 
deep,  for  the  mortification  of  the  pedicle  is  seldom  arrested  at  the 
level  of  the  elastic  ligature.  This  cicatrix  formed  at  a  weak  part 
often  makes  it  necessary  for  the  patient  to  wear  an  abdominal  sup- 
porter. If  the  ovaries  have  not  been  removed,  there  is  observed  at 
each  menstrual  period  a  discharge  of  blood  from  the  scar.  There  may 
even  be  a  persistent  cervico-abdominal  fistula. 

Dropped  Elastic  Ligature. — Whatever  may  have  been  done  in 
this  direction  by  Czerny 38  and  Kaltenbach,29  it  was  Olshausen 30  who 
first  recommended  retention  of  the  elastic  ligature.  It  is  applied 
as  for  the  external  method  and  then  sutured  about  the  pedicle 
with  silk  thread  to  prevent  its  slipping.  Olshausen  employed  this 
procedure  occasionally  where  the  hemorrhage  was  very  difficult  to 
control,  yet,  though  very  successful,  he  has  to-day  relinquished  it.31 
The  pedicle  thus  ligated  does  not  mortify  but  continues  to  derive 
nourishment,  either  through  the  base  or  through  adjacent  adhesions; 
its  nutrition  is,  however,  very  scant,  and  it  undergoes  a  granulo-fatty 
degeneration.  There  have  also  been  cases  where  it  has  suppurated  and 
caused  serious  symptoms  with  the  elimination  of  the  ligature  (Hegar) 
or  fatal  peritonitis  (Olshausen,  Czerny,  Hegar).  At  other  times  the 
ligature  has  been  expelled  without  inconvenience  to  the  patient.  Ahl- 
f eld 32  cites  an  instance  which  the  surgeon  complicated  by  fastening 
the  ligature,  after  having  taken  two  turns  about  the  pedicle,  with  a 
ring  of  lead  5  mm.  in  diameter,  which  he  crushed  about  the  rubber 
with  strong  forceps.  This  mode  of  fixing  the  ligature  had  already 
been  employed  by  Thiersch,33  but  only  for  extra-peritoneal  treatment, 
and  was  then  adopted  by  Sanger, 34  who  later  abandoned  it  for  his 
mixed  method  after  obtaining  nine  successes  without  a  single  failure. 


TEEATME1STT  OF  FIBROUS  TUMORS  OF  ABDOMINAL  EVOLUTION.     293 


The  following  procedures  are  cited  only  because  of  their  originality : 
Schwarz 35  has  proposed  to  cover  the  elastic  ligature  with  a  fold 

of  peritoneum  cut  from  the  pedicle. 

Meinert 36  has  proposed  to  open  Douglas'  pouch  and  pass  the  pedicle 

into  the  vagina;  he  made  the  experiment  once  but  the  patient  died. 


Fig.  155.— Ligature  of  the  Pedicle!  by  Zweifel's  Method.  A,  Transfixion  of  pedicle  with  needle 
armed  first  with  threads  la  and  lb;  B,  first  thread  withdrawn  and  second  Ha  and  lib  passed  through  eye 
of  needle,  which  is  then  withdrawn;  C,  needle  re-introduced  with  thread  Ila  and  lib  a  finger's  breadth 
from  the  first  puncture;  this  is  repeated  with  the  third  thread  and  so  on;  D,  pedicle  traversed  by  a  series 
of  loops  disposed  for  partial  juxtaposed  ligature. 


294 


CLINICAL   AND   OPERATIVE   GYNECOLOGY. 


Hysterectomy  lias  been  performed  in  two  stages;  the  first  con- 
sisting in  opening  the  peritoneum  and  the  production  of  adhesions; 
the  second,  of  the  removal  of  the  tumor.  Nussbaum 37  has  employed 
this  dangerous  method  in  the  case  of  a  suppurating  myoma;  the 
patient  died.  Vulliet 38  has  recently  adopted  it,  but  his  patient,  when 
he  published  his  case,  had  not  recovered. 

1  Continuous  Fractional  Ligature  (Fortlaufende  Partienligatur). 
—Under  this  name  Zweifel  has  described  a  method*  of  suturing  the 
pedicle  which  certainly  assures  better  hsemostasis  than  Schroder's, 


Fig.  156. -Ligature  of  the  Pedicle  by  Zweifel's  Method.    Suture  of  the  broad  ligament,  and 
application  of  temporary  elastic  ligature. 

but  seems,  a.  priori,  inferior  in  technique  as  regards  primary  union  of 
the  stump  and  its  chances  of  sloughing;  however,  the  good  results 
published  by  Zweifel  demand  attention. 

In  ten  cases  with  his  method 39  there  was  but  one  death  when  he 
published  his  book  (1888),  and  in  February,  1889,  he  announced  a 
series  of  twenty -two  successful  cases.  His  technique  is  as  follows: 
For  all  his  ligatures  he  employs  sterilized  silk  and  a  needle  furnished 
with  a  groove  which  resembles  Reverdin's;  the  point  is  blunt.  He 
first  ties  the  broad  ligaments  with  chain  sutures.  He  then  divides 
them  and  applies  the  elastic  cord,  the  ligatures  nearest  the  uterus 
being  left  long  and  the  elastic  cord  passed  over  them  (Fig.  156). 


TREATMENT  OF  FIBROUS  TUMORS  OF  ABDOMINAL  EVOLUTION.     295 

In  the  excision  of  the  tumor  a  small  musculo-peritoneal  lip  is  pre- 
served both  before  and  behind  (Fig.  157),  and  the  cavity  of  the  uterus 
and  cervix  are  cauterized  with  the  thermo-cautery.  A  sharp  needle 
is  then  threaded  and  a  series  of  partial  ligatures  passed,  of  which  the 
figure  (155)  gives  a  sufficient  explanation.  The  peritoneum  is  closed  by 
a  series  of  superficial  sutures  (Fig.  158).  Drainage  through  the  vagina 
by  the  cross-tube  is  necessary  only  when  there  is  persistent  oozing. 

Mixed  Method  (It  might  also  be  called  juxta-parietal). — Owing  to 
the  difficulty  which  some  surgeons  have  found  in  fixing  a  short  pedi- 
cle in  the  abdominal  wound,  it  has  been  abandoned  within  the  cavity 


Fig.  157.— Ligature  of  the  Pedicle  by  Zweifel's  Method.    Showing  the 
form  of  the  incision  by  which  the  pedicle  is  formed. 


Fig.  158.  —  Ligature  op 
the  Pedicle  by  Zweifel's 
Method.  Showing  theco- 
aptation  by  the  partial  lig- 
atures and  the  superficial 
peritoneal  sutures. 


of  the  abdomen  as  in  the  successful  case  of  Kleeberg,  of  Odessa,  whom 
I  have  cited  as  the  inventor  of  the  elastic  ligature,  and  who  in  1887 
allowed  a  thick  and  short  stump  to  drop  back  into  the  peritoneal 
cavity,  bringing  out  the  ends  of  the  constricting  ligature  through  the 
lower  angle  of  the  abdominal  wound.  Pean  has  at  times  left  a  bundle 
of  forceps  projecting  from  the  abdomen,  with  success.  But  these  were 
all  procedures  of  necessity.  Fixation  of  the  pedicle  immediately  be- 
low or  in  the  thickness  of  the  abdominal  walls,  with  permanent  com- 
munication exteriorly  at  this  level,  has  been  lately  proposed  and 
carried  out  as  a  procedure  of  choice,  with  the  intention  of  permitting 
examination  where  the  haemostasis  has  been  difficult,  and  to  insure  the 


296 


CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 


external  discharge  of  products  which  could  infect  the  peritoneum. 
The  first  to  apply  a  mixed  method  was  probably  Freund 40  who,  after 
amputation  of  a  voluminous  uterine  tumor,  made  one  bundle  of  stump 
and  broad  ligaments,  passed  an  elastic  cord  about  them  and  covered 
their  extremities  with  a  condom  whose  lower  shut  extremity  he  cut 
off ;  into  this  he  passed  a  glass  tube  to  the  pedicle,  brought  the  extremi- 
ties of  the  elastic  ligature  out  of  it,  and  packed  with  iodoform  gauze. 
The  patient  recovered.  It  is  very  evident  that  the  rapid  formation  of 
protecting  adhesions,  and  not  the  condom,  made  the  barrier  against 


Pig.  159,— Woelfler-Hacker's  Mixed  Treatment  of  the  Pedicle,    c,  Skin;  m,  muscular  layers ;  pp, 
parietal  peritoneum;  d,  drain;  ut,  pedicle.    Median  section ;  diagrammatic. 


infection  of  the  peritoneum ;  tamponing  with  iodoform  gauze  above 
the  pedicle  would  have  been  both  more  simple  and  more  sure. 

Two  surgeons  of  Vienna,  pupils  of  Billroth,  Wolfler  and  Yon 
Hacker,41  and  Sanger,  of  Leipsic,42  have  lately  proposed  a  mixed 
method  which  deserves  to  be  described  in  detail.  Hacker  conceived 
the  method,  inspired  by  a  case  of  Billroth'^,43  and  first  performed  it, 
August  31st,  1834. 

Wolfler --Hacker 's  Method. — The  pedicle  is  sutured  according  to 
Schroder's  method  and  is  then  dropped  back,  so  that  its  summit  lies 
against  the  deeper  surface  of  the  abdominal  wall;  it  is  fixed  there, 
close  to  the  peritoneal  incision,  by  passing  through  it  on  each  side 
a  carbolized  silk  suture  which  traverses  its  superficial  layers  and 


TREATMENT  OF  FIBROUS  TUMORS  OF  ABDOMINAL  EVOLUTION.     297 

then  the  abdominal  walls.  The  ends  of  the  silk  are  looped  over  small 
rolls  of  iodoform  gauze  and  tied  so  that  the  surface  of  the  stump  is 
held  between  the  lips  of  the  peritoneal  wound.  The  edges  of  the 
parietal  peritoneum  are  not  sutured  together  at  this  point,  but  are 
carefully  stitched  around  the  top  of  the  pedicle  so  that  it,  as  regards 
the  abdominal  cavity,  is  extra-peritoneal,  and  yet  juxta-parietal.  The 
abdominal  walls  are  then  sutured,  leaving  only  room  for  a  band  of 
iodoform  gauze  and  the  drain  which  is  passed  down  to  the  pedicle 
(Figs.  159, 160). 

The  first  two  cases  of  Wolfler  and  Hacker  recovered  with  but 
little  suppuration  or  sloughing;  both  would  probably  have  died  of 
septic  peritonitis  if  the  pedicle  had  been  abandoned  within  the  ab- 


Fig.  160.— Woelfler-Hacker's  Mixed  Treatment  of  the  Pedicle,  c,  Skin;  m,  muscles;  pp.  parietal 
peritoneum;  pv,  visceral  peritoneum;  ut,  pedicle;  a,  cutaneous  suture;  6,  muscular  suture;  c,  peritoneal 
suture  with  catgut;  e,  pedicle  supports  on  rolls  of  iodoform  gauze.    Transverse  section;  diagrammatic. 

dominal  cavity;  then  followed  a  number  of  cures  by  first  intention. 
Fritsch  adopted  the  method,  and  obtained  nineteen  successive  suc- 
cesses, while  Olshausen's  and  Schroder's  method  had  given  twelve 
deaths  in  thirty-nine  cases.  Although  I  have  not  adopted  it  ex- 
clusively, it  is  certain  that  the  method  is  a  very  useful  one,  for  it 
is  applicable  both  to  large  and  to  short  pedicles,  which  could  not 
be  drawn  out  of  the  abdominal  wound  without  too  much  effort 
and  where  the  abundance  of  the  vessels  and  the  number  of  the 
ligatures  would  render  abandonment  in  the  abdomen  dangerous,  be- 
cause of  the  probability  of  secondary  hemorrhage,  mortification,  and 
septicaemia. 

Sanger's  Method. — Intra-peritoneal  sequestration  (Abkapselung). 
— Sanger  thus  designates  an  operative  procedure  which  consists  of 
suturing  the  peritoneum  closely  about  the  pedicle,  drawing  upon  the 
parietal  peritoneum  for  this  purpose,  and  fixing  it  along  the  posterior 


298 


CLINICAL  AND   OPEEATIVE   GYNECOLOGY. 


face  of  the  stump.     The  abdominal  cavity  is  thus  separated  from  its 
lower  division,  in  which  lies  the  sequestrated  pedicle. 

Sanger  distinguishes  two  modifications  of  this  procedure: 

1.  The  pedicle  is  sutured  by  Schroder's  method  but,  hemorrhage 
being  probable,  it  is  sequestrated  by  suturing  to  it  the  parietal  perito- 
neum, with  drainage  (Fig.  161). 

2.  The  pedicle  is  too  short  to  be  drawn  out  of  the  abdomen.  The 
transfixing  pins  are  placed  some  distance  above  the  elastic  ligature, 
which  is  disposed  as  in  Hegar's  method.  The  peritoneum  is  then 
sutured  to  the  upper  part  of  the  pedicle  in  front  of  the  elastic  liga- 


Fig,  161.— Sanger's  Mixed  Treatment  of  the  Pedicle;  Intra-peritoneal  Sequestration  of  a  Pedicle 
Sutured  by  Schroeder's  Method,  pp,  Parietal  peritoneum  sutured  to  posterior  surface  of  stump;  u, 
uterine  pedicle;  v,  vagina;  d,  drainage. 

ture,  to  sequestrate  it  from  the  abdominal  cavity.  A  barrier  is  thus 
formed  above,  making  the  elastic  ligature  extra-peritoneal  and  yet 
intra-abdominal  (Fig.  162).  Sanger  has  thus  obtained  great  success 
with  a  stump  which  was  very  short,  thick,  and  hemorrhagic. 

A  careful  study  of  these  two  methods  demonstrates  that  the 
first  of  Sanger's  does  not  differ  materially  from  Wolfler-Hacker's,  for 
the  two  lateral  sutures  for  the  suspension  of  the  uterus  are  replaced 
by  the  suture  of  the  peritoneum  to  the  posterior  face  of  the  stump. 
As  to  the  second,  it  is  practically  Hegar's  method  applied  to  a  very 
short  stump,  where  the  suture  around  the  pedicle  is  replaced  by  the 
suture  above  it  of  the  peritoneum ;  but  it  presents  this  originality, 
that  the  peritoneum  is  sutured  (with  catgut)  above  the  elastic  ligature 


TREATMENT  OF  FIBROUS  TUMORS  OF  ABDOMINAL  EVOLUTION.     29£ 

to  the  part  which  is  intended  to  slough.  Sanger  powders  the  stump 
with  a  mixture  of  salicylic  acid,  iodoform,  and  tannin ;  to  this  I  add 
a  covering  of  iodoform  gauze. 

Extirpation  of  the  Pedicle— Total  Hysterectomy.— -In  those  rare 
cases  where  the  cervix  is  so  full  of  fibrous  tumors  that  it  is  impossible 
to  save  a  pedicle,  we  may  be  obliged  to  perform  total  hysterectomy. 
Practically,  by  placing  an  elastic  ligature  upon  the  capsule,  it  is  almost 


Fig.  162.— Treatment  op  the  Pedicle  by  Saenger's  Mixed  Method.  Intra-peritoneal  sequestration  of 
the  pedicle,  with  elastic  ligature.  I,  elastic  ligature;  ut,  posterior  surface  of  uterus;  p,  pedicle  (section); 
b,  pins. 

always  possible  to  save  a  pedicle  in  enucleating  and  excising  the  stump, 
and  if  this  is  too  short  to  be  maintained  externally,  the  mixed  method 
may  be  adopted  or  it  may  be  abandoned  in  the  peritoneum.  The  pro- 
cedures of  Olshausen  and  Sanger  do  not  seem  to  me  less  serious  than 
total  extirpation,  even  though  Bardenheuer  has  recorded  six  success- 
ful cases  with  them  in  seven  operations ;  his  cases  appearing  to  have 
been  simple  ones  which  would  have  recovered  with  any  other  method. 
The  cases  published  since  then  have  not  been  very  numerous,  which 
proves  the  legitimate  objection  to  the  application  to  fibroma  of 
Freund's  operation  for  cancer,  which  is  to-day  condemned.44 


300  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

Of  late,  however,  there  has  been  an  attempt  to  revive  total  extir- 
pation. Martin45  has  advocated  it.  He  first  does  a  supra-vaginal 
hysterectomy,  after  applying  the  provisional  elastic  ligature,  then  an 
assistant  frees  the  cervix  by  the  vagina  and  the  surgeon  completes 
the  operation  through  the  abdomen  by  tying  the  broad  ligaments 
and  separating  the  bladder.  Martin  advises  that  the  intestines  be 
protected  by  a  sponge  full  of  antiseptic  oil,  thinking  that  he  thus  pre- 
vents the  formation  of  adhesions.  T.  J.  Croiford46  has  published  one 
successful  case,  but  his  technique  (he  employed  the  ecraseur)  seems 
very  defective. 

Bardenheuer  has  recommended  as  a  procedure  of  choice,  even  in 
simple  cases,  to  evert  the  broad  ligaments  toward  the  vagina,  holding 
them  in  position  by  sutures,  thus  facilitating  drainage.47 

IV.  Intra-ligamentous  and  Pelvic  Fibroma — Decortication, — Fi- 
bromata from  the  supra- vaginal  portion  of  the  cervix  and  the  lower 
part  of  the  body  of  the  uterus  grow  below  the  peritoneum,  which  they 
elevate  and  unfold  and  are  seldom  covered  by  it  completely,  having 
a  tendency  to  insinuate  themselves  into  the  cellular  spaces  of  the  pel- 
vic floor.  They  may  thus  split  the  meso-rectum  up  to  the  superior 
strait,  or  lift  up  the  utero-vesical  pouch  and  compress  the  bladder 
against  the  pubic  bone,  or,  as  in  the  great  majority  of  cases,  they  may 
spread  into  the  broad  ligaments,  whose  folds  they  entirely  efface. 
Prom  the  surgical  point  of  view  all  these  varieties  belong  in  one 
natural  group,  characterized  by  extreme  difficulty  in  forming  a  pedi- 
cle and  intimate  and  extended  connections  with  the  walls  and  viscera 
of  the  lesser  pelvic  cavity. 

The  surgical  treatment  of  these  tumors  is  attended  by  the  greatest 
difficulties.  After  opening  the  abdomen,  if  they  appear  too  large  for 
extirpation  to  offer  real  chance  of  recovery,  we  may  perform  castra- 
tion (palliative)  in  place  of  extirpation  (curative).  We  must,  how- 
ever, recognize  that  in  these  cases  it  is  not  the  hemorrhage  which  is 
the  most  important  symptom,  but  the  compression,  and  that  therefore 
castration  has  but  an  uncertain  value;  if  performed,  it  is  only  as  a 
makeshift. 

I  propose  to  reserve  the  term  "  decortication  "  for  the  extraction  of 
the  tumor  from  its  cellular  bed,  and  the  term  "  enucleation  "  for  its 
removal  from  the  uterine  tissue ;  the  use  of  the  latter  word  for  the  two 
operations,  so  different  in  their  natures,  has  given  rise  to  great  con- 
fusion. It  is  impossible  to  give  a  typical  description  to  cases  which 
are  beyond  all  rules  and  hence  termed  "  atypical." 


TKEATMENT  OF  FIBROUS  TUMORS  OF  ABDOMINAL  EVOLUTION.     301 

The  application  of  the  provisional  elastic  ligature  is  seldom  possi- 
ble, and  then  only  on  a  part  of  the  tumor.  Redoubled  care  must 
be  employed  not  to  include  the  portion  of  the  bladder  which  is  gener- 
ally elongated  upon  the  anterior  face  of  the  uterus.  If  part  of  the 
tumor  projects  far  into  the  peritoneal  cavity,  the  ligature  is  placed  as 
deeply  as  possible  about  this  lobe,  which  may  then  be  removed  with- 
out fear.  An  attempt  is  made  to  enucleate  the  deeper  parts  by  strong 
traction,  the  elastic  cord  following  the  diminution  of  the  tumor  and 
keeping  up  a  steady  and  sufficient  constriction  upon  the  capsule  as  it 
is  emptied.  Very  often  it  is  necessary  to  begin  the  operation  by  liga- 
tion and  section  of  the  adnexa  on  the  side  where  we  are  operating,  at 
the  same  time  placing  a  deep  ligature  on  the  corresponding  trunk  of 
the  uterine  artery. 

It  may  occur  that  these  manoeuvres  are  impossible,  and  that  we 
must  proceed  at  once  to  the  important  step  of  the  operation,  namely, 
the  free  incision  of  the  tumor's  intra-ligamentous  seat,  whose  lips  are 
then  seized  by  strong  forceps,  and  the  decortication  accomplished 
with  fingers  and  spatula.  The  operator  keeps  up  strong  traction  with 
toothed  forceps,  carefully  dissects  out  the  neoplasm  and  applies 
clamps  to  bleeding  points,  without  forgetting  the  position  of  the  ure- 
ters; the  tumor  once  removed,  he  sees  the  veins  of  the  broad  liga- 
ments, which  are  at  times  enormous,  and  is  surprised  to  require  more 
ligatures1  than  he  had  thought  necessary. 

When  the  connections  of  the  tumor  to  the  uterus  are  not  exten- 
sive, it  is  sufficient  to  apply  haemostatic  ligatures  or  sutures  as  neces- 
sary, and  leave  the  organ  in  place;  but  if  they  are  close  and  the 
bleeding  is  hard  to  stop,  it  is  better  to  decide  on  supra-vaginal  hyster- 
ectomy without  further  hesitation.  It  may  occur  that  this  happens 
almost  without  our  knowledge,  for  at  the  end  of  a  laborious  decorti- 
cation we  may  reach,  in  a  tumor  which  fills  the  pelvis,  a  pedicle  which 
is  at  once  recognized  as  the  cervix. 

The  resulting  cavity  may  be  very  large,  with  prolongations  toward 
the  rectum,  bladder,  or  on  each  side  of  the  vagina ;  its  treatment  may 
be  according  to  one  of  the  following  plans : 

If  we  feel  perfectly 'sure  that  the  operation  has  been  aseptic,  we 
may  try  for  primary  union  without  drainage.  If  the  peritoneum  has 
not  been  torn  or  contused,  as  is  the  case  with  small  tumors  and  where 
the  adhesions  are  loose,  a  few  points  of  suture  are  placed  in  the  mem- 
brane to  unite  it,  the  peritoneal  toilet  is  then  completed  and  the  ab- 
domen closed.     If  the  pocket  is  very  deep  and  the  bleeding  is  free, 


302 


CLIXICAL   AND    OPERATIVE    GYNECOLOGY. 


we  may  make  a  continuous  suture  in  terraces,  which  both  unites  the 
parts  and  stops  the  hemorrhage.  Debris  which  may  mortify  should 
be  excised. 


Fig.  163. — Intra-ligamentous  Fibroma.  A,  Horizontal  section  to  show  the  connections  of  the  tumor; 
-weight  14  lbs.;  B,  suture  of  the  cavity  resulting  from  enucleation  of  the  preceding;  drainage  by  the 
vagina;  cure  (Kaltenbaeh). 

This  bold  procedure  is  justified  only  in  exceptional  cases ;  if  the 
cavity  is  extensive  and  we  fear  oozing,  drainage  is  more  prudent. 


Fig.  164.— Fibroma  in  the  Broad  Ligament;  Decortication  and  Suture  of  the  Cavity,  and  Drainage 

by  the  Vagina  (Martin). 

It  may  be  performed  in  two  ways ;  Martin 4S  and  Kaltenbach 49  recom- 
mend the  use  of  a  cross-tube  through  the  vagina,  passed  through  the 
cul-de-sac.     Sanger,  after  dropping  the  pedicle  left  by  the  removal  of 


TREATMENT  OF  FIBROUS  TUMORS  OF  ABDOMINAL  EVOLUTION.      303 

a  tumor  from  just  above  the  cervix,  closed  the  abdominal  walls  and 
immediately  opened  by  the  vagina  and  packed  with  gauze  the  capsule 
filled  with  blood  which  projected  into  it ;  his  patient  recovered.50 

Drainage  through  the  inferior  angle  of  the  abdominal  wound 
is  'preferable  in  some  cases,  according  to  the  situation  of  the  cav- 
ity; it  has  the  advantage  of  exposing  less  to  infection.  Terrier51 
has  recently  treated  in  this  way  the  cavity  of  a  myoma  of  the  broad 
ligament;  recovery,  with  permanent  fistula.  H.  A.  Kelly52  decorti- 
cated a  pelvic  fibroma  which  had  compressed  the  bladder,  left  open 
and  drained  the  cavity,  and  then  used  weak  carbolic  injections 
through  the  drain  without  fear  of  effusion  into  the  peritoneum, 
which  was  closed  off  during  the  first  days  by  adhesions.  I  prefer  to 
emrjloy  iodoform  gauze,  as  it  is  at  once  a  haemostatic  and  a  capillary 
drain,  and  I  have  used  it  with  success  in  one  case  of  intra-ligamentous 
tumor  which  weighed  fifteen  pounds.53  Kiister 54  has  also  packed  the 
cavity  and  united  its  edges  to  the  lower  part  of  the  abdominal  wound. 
The  gauze  should  be  withdrawn  a  little  at  a  time  and  replaced  by  a 
drain  at  the  end  of  a  few  days. 

Tauffer55  has  had  curious  success  by  partially  resecting  large 
fibromata  of  the  ligaments,  fixing  the  stump  in  the  abdominal  wound, 
and  then  treating  it  by  strong  cauterization  with  chloride  of  zinc. 

Operative  Accidents. — Hemorrhage  is  one  of  the  most  serious 
dangers,  and  has  caused  many  deaths  upon  the  operating  table,  but 
it  may  be  avoided  by  the  judicious  use  of  the  temporary  elastic  liga- 
ture. It  must  be  noted  that  we  do  not  produce  here,  as  in  the  appli- 
cation of  the  Esmarch  bandage  to  a  limb,  an  ischsemia  of  the  tumor; 
this  idea  of  L.  Labbe's,  though  ingenious,  is  still  pure  hypothesis; 
and  beside  the  almost  insurmountable  difficulties  in  application,  it 
exposes  to  excessive  manipulation,  and  without  doubt  to  embolism. 
We  must  not  be  surprised,  therefore,  on  cutting  the  tumor  above  the 
ligature,  to  see  a  large  discharge  of  residual  blood  which  has  been  im- 
prisoned by  it.  If  the  case  is  one  of  telangiectatic  tumor  or  if  the 
broad  ligaments  are  traversed  by  dilated  veins  (tubo-ovarian  varico- 
cele), the  ligaments  must  be  tied  with  the  greatest  care  and  cut  only 
between  two  ligatures.  The  threads  should  be  passed  with  a  dull 
needle  to  avoid  puncture  of  the  vessels — an  accident  which  has  often 
caused  large  subserous  hemorrhages,  and  to  save  time  the  ligatures 
may  be  replaced  by  long  forceps. 

In  cutting  the  tumor  above  the  ligature,  the  greatest  care  must  be 
exercised  to  prevent  the  section  from  going  too  near  the  elastic  band 


304  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

and  thus  allowing  the' escape  through  it  of  any  part  of  the  tumor's 
pedicle  from  the  constriction  of  its  circumference.  The  extra-perito- 
neal treatment  of  the  pedicle,  with  the  use  of  the  elastic  ligature, 
permits  us  to  avoid  all  secondary  hemorrhage,  but  with  the  intra-peri- 
toneal  method  (suturing  the  stump  with  catgut  or  silk),  this  is  not 
the  case  even  though  the  uterine  arteries  be  strongly  ligated  to  right 
and  left  of  the  pedicle  by  passing  a  stout  needle  through  a  certain 
thickness  of  the  organ.  In  spite  of  this  precaution,  we  often  see  fatal 
hemorrhage  from  shrinking  of  the  tissues  and  relaxation  of  the  liga- 
ture a  few  hours  or  days  later. 

The  possibility  of  wounding  the  bladder  should  always  be  remem- 
bered. The  cases  are  numerous  where  it  has  been  lacerated,  or  partly 
included  in  the  permanent  ligature.  If  the  viscus  is  elongated  in 
front  of  the  tumor  it  must  be  dissected  off  sufficiently  to  allow  the  liga- 
ture to  be  placed  below  it. 

When  the  bladder  is  extensively  wounded,56  it  should  be  closed 
immediately  by  a  continuous  catgut  suture  on  two  or  three  planes. 
Catgut  is  preferable  when  the  stump  has  been  treated  by  the  extra- 
peritoneal method,  for  silk  is  porous  and  may  cause  infection  by 
absorbing  the  secretions  from  the  furrow  around  the  pedicle.  When 
the  stump  is  abandoned  within  the  peritoneum,  as  in  myomectomy, 
silk  may  be  used.  A  soft  catheter  furnished  with  a  tube  forming  a 
siphon  should  be  left  in  the  bladder  for  ten  days  after  the  operation. 
Leopold  has  had  complete  success  with  this  method,  and  I  have  em- 
ployed it  in  a  case  of  bladder  wound  12  cm.  in  length,  which  was 
perfectly  cured  although  the  patient  removed  the  catheter  after  six 
days  and  caused  a  partial  temporary  disunion  of  the  vesical  suture, 
which  was  rendered  aseptic  by  iodoform  gauze  placed  in  front  of  it. 
In  a  former  case  which  occurred  in  the  course  of  an  ovariotomy, 
where  the  wound  was  enormous  (20  cm.),  I  sutured  its  intra-perito- 
neal  portion  and  maintained  a  small  hole  unsutured  as  a  safety 
valve;  the  patient  recovered  after  a  period  of  temporary  fistula, 
which  was  easily  effaced  by  freshening  its  edge. 

Sanger  adopted  a  different  procedure  in  a  case  where  the  elongated 
bladder  was  taken  for  the  pedicle  of  an  ovarian  tumor  and  included 
in  the  sutures,  retaining  these  and  closing  the  peritoneum  around 
and  above  the  vesical  stump  by  sequestration  similar  to  that  em- 
ployed for  the  uterine  pedicle:  cure  without  fistula.  A  permeable 
urachus,  divided  during  the  operation,  has  rarely  caused  fistula;  these , 
have,  however,  a  tendency  to  heal  spontaneously  (Atlee,  Sanger).    It 


TREATMENT  OF  FIBROUS  TUMORS  OF  ABDOMINAL  EVOLUTION.     305 

is  well  to  carry  the  incision  of  the  abdomen  outside  of  this  cord  when 
it  is  encountered,  and  if  slightly  wounded,  it  should  be  sewn  into  the 
abdominal  wall  by  one  or  two  deep  sutures  (Spencer  Wells).  If  the 
wound  in  it  is  very  extensive,  it  may  be  closed  by  a  few  sutures  and 
the  patient  catheterized  every  three  hours  to  prevent  distention  of 
the  bladder. 

I  am  inclined  to  think  that  the  ureter  has  often  been  ligated  dur- 
ing hffimostasis  of  the  stump  which  is  returned  to  the  abdomen,  and 
in  decortication  of  intra-ligamentous  fibromata,  and  that  many  of  the 
deaths  attributed  to  shock  are  really  due  to  this  accident.  The  rela- 
tions of  these  ducts  should  never  be  forgotten  in  placing  deep  liga- 
tures on  the  sides  of  the  uterine  neck. 

The  intestines  may  be  simply  applied  to  the  surface  of  a  fibroma 
which  splits  the  mesocolon,  and  it  is  then  easy  to  separate  them  by 
the  finger,  or  there  may  be  firm  union  between  them  when  the  tumor 
derives  its  nutrient  vessels  from  such  adhesions,  as  I  have  observed 
in  the  case  of  a  large  subperitoneal  fibroma  with  a  narrow  and  small 
vascular  pedicle.  A  thin  layer  of  the  tumor  is  then  to  be  left  adher- 
ent to  the  intestine,  which  if  not  too  extensive  may  be  folded  upon 
itself  and  sutured  (Fig.  150).  If,  however,  a  large  surface  of  the  in- 
testine has  thus  been  wounded,  we  take  the  risk  of  contracting  the 
digestive  tube  by  coaptation  of  the  bleeding  part ;  it  is  then  better 
to  touch  it  lightly  with  the  thermo-cautery  and  fix  it  to  the  parietal 
peritoneum  by  a  few  catgut  sutures,  as  near  as  possible  to  the  ab- 
dominal drain.  To  simply  abandon  it  within  the  abdomen  would  be 
to  produce  conditions  that  would  favor  an  attack  of  ileus. 

Causes  of  Death  after  Abdominal  Hysterectomy. — Hemorrhage, 
septicemia,  and  the  complex  syndroma  called  shock  are  the  chief 
causes  of  death  after  operation;  less  often  it  is  due  to  embolism,  ileus, 
or  tetanus. 

I  have  already  spoken  of  primary  hemorrhage  at  the  time  of  oper- 
ation. In  Schroder's  method  secondary  bleeding  is  always  to  be 
feared  and  is  announced  by  the  extreme  agitation  of  the  patient,  the 
accelerated,  irregular,  small  pulse,  and  pallor  of  the  integument  and 
mucous  surfaces.  In  other  cases  we  may  find  a  serous  fluid  oozing 
out  between  the  sutures,  or  the  patient  describes  a  pleasant  sensa- 
tion as  of  a  jet  of  hot  water  flowing  through  the  abdomen.  The 
blood  may  escape  in  great  amount  below  the  peritoneum  between  the 
broad   ligaments,   forming   enormous   retro-peritoneal   hematoceles, 

or  it  may  accumulate  in  the  seat  of  the  enucleated  tumor,  project- 
20 


306  CLINICAL   AND    OPEEATIVE   GYNECOLOGY. 

ing  through  the  ecchymosed  vagina  and  pressing  it  strongly  down- 
ward. 

If  there  is  reason  to  suspect  an  internal  hemorrhage,  there  should 
be  no  delay  in  opening  the  abdomen,  both  to  tie  the  bleeding  vessels 
and  to  remove  the  clots  which  form  an  excellent  culture  medium  for 
the  microbes  which  enter  from  without,  by  the  tubes,  or  from  within, 
through  the  wall  of  the  paralyzed  intestine.  0.  Kiistner 37  reports  a 
remarkable  case  which  he  saved  in  this  manner,  where  the  bleeding 
came  from  the  pedicle  in  the  abdomen  after  ovariotomy.  If  the  state 
of  the  circulation  permits  and  the  heart's  action  is  not  too  much  com- 
promised, a  litre  of  sterilized  water  at  38°  C.  (100°  F.),  containing  chlo- 
ride of  sodium  (6  : 1,000)  may  be  injected  by  the  cephalic  vein.  For 
this  purpose  we  may  use  a  small  canula,  passed  through  an  alcohol 
flanie,  and  a  funnel  of  glass  furnished  with  a  rubber  tube  a  yard  in 
length,  sterilized  with  boiling  water.  If  the  pulse  is  weak,  and  it 
seems  dangerous  to  suddenly  increase  the  contents  of  the  vessels, 
injections  of  water  and  chloride  of  sodium,  100  to  200  gm.  at  a  time, 
may  be  given  into  the  subcutaneous  cellular  tissue; 58  the  fluid  is  very 
quickly  absorbed. 

Septicaemia  may  occur  in  several  ways — either  from  defective  asep- 
sis during  the  operation,  or,  more  frequently,  from  germs  introduced 
from  without  through  the  pedicle;  hence  the  precautions  recom- 
mended for  destruction  of  the  mucous  membrane,  careful  junction  of 
the  surfaces  to  obtain  complete  occlusion,  and  the  other  methods  of 
treating  the  pedicle. 

The  constriction  of  the  sutures  does  not  account  for  the  sloughing 
of  the  pedicle  after  it  has  been  returned  to  the  abdomen ;  to  produce 
mortification,  the  action  of  germs  is  indispensable.  If  kept  aseptic, 
the  tissues  deprived  of  their  circulation  undergo  a  granulo-fatty  de- 
generation. The  circulation  may  be  re-established  by  the  formation 
of  adhesions  or  bridges  of  tissue  above  the  pedicle,  which  is  thus  little 
by  little  encapsuled.  There  are  records  of  a  slow  or  secondary  infec- 
tion of  the  dropped  stump  by  means  of  the  sutures  when  they  are  of 
silk,  or  by  the  elastic  cord.  The  germs  may  then  come  through  the 
tubes  or  the  intestine,  following  a  temporary  stasis  of  its  contents; 
and  in  certain  cases  we  must  suppose  a  latent  microbism.  Whatever 
the  origin  may  be,  cases  of  death  from  pelvic  inflammation  and  sup- 
puration are  not  very  uncommon. 

Abroad,  and  also  in  France,  death  has  been  ascribed,  after  grave 
and  protracted  operations,  to  a  combination  of  depression  synrptoms 


TREATMENT  OF  FIBROUS  TUMORS  OF  ABDOMINAL  EVOLUTION.     307 

called  "shock."  There  is  no  doubt  that  a  number  of  such  cases  are 
to  be  attributed  to  hemorrhage,  of  which  some  surgeons  are  too  un- 
willing to  allow  the  importance ;  others  may  be  due  to  acute  uraemia 
from  accidental  ligation  of  the  ureters  or  abolition  of  the  function 
of  kidneys  already  seriously  impaired  by  the  influence  of  trauma- 
tism and  absorption  of  the  anaesthetic.  Degeneration  of  the  heart 
(Hofmeier59)  may  also  be  the  cause  in  many  cases  (p.  234),  such 
myocarditis  being  more  frequent  than  is  supposed.  Cohnheim 60  has 
shown  that  persistent  hemorrhage  alone  is  enough  to  produce  a  fatty 
change  in  the  cardiac  muscle.  Ungar  and  Strassmann 61  have  called 
attention  to  the  action  of  the  chloroform  in  these  cases;  and  many 
authors 62  have  proved  that  the  antiseptics  act  strongly  on  the  heart. 
Some  of  these  depression  phenomena  are  due  to  the  exposure  of  the 
viscera  and  the  handling  which  they  receive,  as  is  evident  from  the 
experiments  of  Goltz  on  abdominal  shock  and  of  Olshausen.on  evis- 
ceration.63 To  these  numerous  causes  of  depression  Landau64  has 
added  chronic  intoxication  from  ergot,  producing  enf eeblement  of  the 
heart,65  and  a  similar  condition  from  iodine.66  These  substances  have 
at  times  been  taken  in  very  large  quantity  by  hypodermic  and  intra- 
uterine injection,  and  their  absorption  may  account  for  some  of  these 
symptoms. 

To  prevent  shock,  it  is  advised  to  adopt  with  weak  patients  the 
mixed  method  of  ansesthesia,  with  a  preliminary  injection  of  mor- 
phine and  atropine.  I  would  also  advise  rapidity  of  operation,  for 
the  depressing  effect  in  every  laparatomy  which  lasts  more  than 
an  hour  is  increased  in  high  proportion.  Contact  of  the  intestines 
with  the  air  must  also  be  carefully  avoided  by  protecting  them 
with  hot  gauze  compresses  and  closing  the  abdominal  wound  as  soon 
as  the  tumor  is  drawn  oat  of  it.  The  incision  should  be  as  small  as 
possible,  passing  the  tumor  as  through  an  elastic  button-hole,  and  aid- 
ing its  issue  from  the  abdomen  by  movements  of  rotation  upon  its 
axis  and  by  elevation  through  the  vagina  by  the  fingers  of  an  assist- 
ant. For  the  depression  and  lowered  temperature,  we  employ  hot 
friction,  and  hypodermic  injection  of  ether,  alternating  every  quarter 
of  an  hour  with  caffeine.  If  acute  anaemia  has  helped  to  cause  the 
accident,  100  to  200  gm.  of  the  salt  solution  may  be  injected  into  the 
sub-clavicular  dorsal  region. 

As  embolism67  has  produced  death  even  during  convalescence, 
we  cannot  insist  too  much  on  absolute  rest,  especially  if  the  tumor 
was  very  vascular  or  the  broad  ligaments  largely  varicose. 


308 


CLINICAL   AND    OPERATIVE   GYNECOLOGY. 


Intestinal  occlusion  has  been  observed  after  hysterectomy,  as  after 
all  other  abdominal  operations,68  but  it  must  not  be  forgotten  that 
some  of  the  cases  published  under  this  head  were  only  pseudo-strangu- 
lation from  paralysis  of  the  intestine,  announcing  a  septic  peritonitis 
which  was  unrecognized. 

To  prevent  this  terrible  complication,  we  should  be  sparing  of  anti- 
septics within  the  abdominal  cavity,  if  we  do  not  abstain  from  them  al- 
together; for  they  exert  an  extremely  intense  action  upon  the  delicate 
epithelium,  and  predispose  to  plastic  exudation.  As  little  bleeding 
surface  should  be  left  in  the  peritoneal  cavity  as  possible:  The 
wound  surface  of  the  stamp  should  be  carefully  covered  with  peri- 
toneum ;  and  the  broad  ligaments,  if  torn  or  divided  in  the  process  of 
decortication,  must  be  secured  with  catgut  sutures. 

As  regards  the  treatment  of  ileus,  before  reopening  the  abdomen 
we  should  try  the  method  proposed  by  Bode  and  Leopold,69  of  plac- 
ing the  patient  upon  her  side  and  giving  forced  enemata  of  hot 
chamomile  infusion,  with  the  addition  of  oil  and  soap. 

Mortality  of  Hysterectomy.  Comparison  of  Results  by  Different 
Methods. — It  is  difficult  to  decide  as  to  the  gravity  of  the  oj>eration, 
as  the  majority  of  authors  do  not  divide  their  cases  according  to 
systems  which  permit  comparison.  Thus  supra-vaginal  amputation 
should  not  be  compared  with  decortication  of  a  large  fibroma ;  there 
is  more  difference  between  them  than  between  amputation  of  the  leg 
and  the  same  operation  .on  the  thigh.  But  in  default  of  anything 
better  we  must  have  recourse  to  statistics.  The  following  are  the 
most  recent — evidently  cases  under  the  old  methods,  where  the  tech- 
nique was  imperfect  and  the  antisepsis  insufficient,  are  not  of  great 
value  for  the  purpose.70  The  first  series  is  borrowed  from  Paul 
Wehmer.71 

A.   Intra-peritoneal  Method. 


Gusserow  12 

Kaltenbach  13  . 

Martin  u 

Olshausen  15 

Spencer  Wells 

Schroder  " 

Tauffer18 


Number  of 
Operations. 

Deaths. 

Mortality. 

19 

6 

31.6    per  cent. 

5 

3 

60 

86 

15 

17.4 

29 

9 

31 

26 

10 

38 

135 

41 

30 

12 

4 

88 

33 

312 

8.2  per  cent, 

'treatment  of  fibrous  tumors  of  abdominal  evolution.    309 


B.  Extra-peritoneal  Method. 


Bantock'9 

Hegar  80 

Kaltenbach  81 . . 

Keith8'2 

Pean  83 

Tauffer 

Spencer  Wells 
Lawson  Tait 85. 
Thornton  86  . . . 


Number  of 
Operations. 

9.9, 


22 

22 
38 
52 
17 
20 
54 
15 

262 


Deaths. 

2 

6 

1 

2 
18 

2 
10 
20 

2 

65 


Mortality. 

9       per  cent 

27 

i 

4.5 

' 

5.3 

i 

34 

i 

11.7 

' 

50 

i 

37 

t 

13 

' 

24      per  cent. 


Zweifel  lias  collected  a  more  recent  series  by  German  surgeons 
("  Die  Stielbehandlung,"  etc.)— 


A.  Extra-peritoneal  Method. 


Carl  Braun  von  Fernwald,87  from  1880  to  1887 

Fehling  88 

Grusserow  89 

Kehrer  90 

Leopold  90 

Saxinger  90 

Schauta  91 

Schultze  90 

Werth  90 

Zweifel 


B.  Intra-peritoneal  Method. 


Carl  Braun  von  Fernwald  9'2 . 

Dohrn93 

Fehling  94  

Gusserow  95 

Kehrer  93 

Leopold  96 

Runge  97 

Saxinger93 

Schauta93 

Schultze  93 

Werth93 

Winckel 93 

Zweifel , , ,  


Number  of 

Operations. 

63- 

15 

3 

9 

14 
10 

5 

1 

9 


130 


Deaths. 

12 
1 
3 
2 
3 
3 
2 
1 
1 
1 

29 


Number  of 

Operations. 

ea 

5 

2 

9 

0 

3 

2 

23 

6 

3 

2 

19 

7 

11 

4 

i 

6 

1 

1 

12 

3 

11 

3 

2 

1 

10 

1 

116 


38 


310  CLINICAL   AND   OPERATIVE  GYNAECOLOGY. 

In  this  series  the  mortality  by  the  extra-peritoneal  method  is 
22.3$,  and,  taking  ont  the  exceptional  results  of  Brann,  it  remains 
25.5$.  By  the  intra-peritoneal  method  it  is  32.7$;  the  relative  be- 
nignity of  the  first  being  thus  clearly  displayed. 

The  following  objection  has  been  made  to  these  figures :  Avowed 
partisans  of  the  extra-peritoneal  method,  like  Kaltenbach,  Thornton, 
and  S.  Keith,  are  found  also  among  those  who  perform  the  intra-peri- 
toneal ;  and  it  is  evident  that  the  two  methods  cannot  be  equally  favored 
in  both  the  series,  and,  very  probably,  where  the  pedicle  was  abandoned 
within  the  abdomen,  the  case  was  more  serious  than  those  where  the 
favored  method  was  employed.  In  order  to  have  a  series  of  statis- 
tics free  from  this  objection,  it  is  well  to  take  the  figures  of  surgeons 
who  practise  the  intra-peritoneal  method  exclusively.  Here  is  such 
a  list,  extracted  from  the  preceding : 


Number  of 
Operations. 

Deaths. 

Mortality. 

86 
29 

15 
9 

17.4    per 
31            ' 

cent 

Schroder 

136 
23 

41 
6 

30.1 

26 

12 

3 

25 

Werth 

11 

3 

27.2 

Dohrn 

9 

0 

0 

19 

7 

36.8 

11 

4 

36.3 

Zweifel — after  exclusive  adoption  of 

his  partial  juxtaposed  ligature — 

10 

1 

10            " 

345 

89 

25.8    per 

cent. 

The  mortality  falls  by  this  list  to  25.8$.  But  if  a  similar  series  as 
regards  the  extra-peritoneal  method  is  made,  leaving  out  the  cases  of 
Schultze  and  Werth,  well-known  partisans  of  the  other  method,  the 
mortality  here  falls  to  21.6$;  the  superiority  is  then  actual,  as  is 
verified  by  the  latest  statistics. 

Tauffer 98  in  51  hysterectomies  had  12  deaths — 22$  (extra-perito- 
neal) ;  Fritsch  "  in  the  operations  where  he  employed  the  extra-peri- 
toneal method,  a  little  modified  to  resemble  Wolfier-Hacker's,  had  23 
cases,  5  deaths,  and,  by  Schroder's  method,  27  cases  and  11  deaths; 
Albert  10°  in  30  cases  had  but  1  death  by  the  extra -peritoneal  method. 

C.  Braun 101  in  his  last  series  of  38  hysterectomies  with  the  extra- 
peritoneal treatment  had  but  6  deaths,  or  15.5$;  and  Hegar102  in  his 
last  series  from  June,  1887,  to  May,  1889,  comprises,  besides  2  myo- 


TREATMENT  OF  FIBROUS  TUMORS  OF  ABDOMINAL  EVOLUTION.     311 

mectomies  for  pedioled  fibroma  with  cure,  also  18  supra-vaginal 
hysterectomies  for  interstitial  tumors  with  cure,  and  12  hysterec- 
tomies for  intraligamentous  tumors  with  2  deaths,  one  at  the  end 
of  four  months  and  the  other  at  the  end  of  five. 

"We  must  not  forget  that  each  one  of  these  methods  has  its  own 
dangers.  The  presence  at  the  bottom  of  the  abdominal  wound  of  a 
stump  destined  to  slough  is  at  the  outset  a  decided  disadvantage  for 
the  extra-peritoneal  method,  although  the  new  dressing  of  powder 
adopted  by  Kaltenbach  lessens  the  inconvenience  which  might  result 
from  the  mortification  of  the  pedicle.  It  should  also  be  noted  of  this 
method  that  the  cure  is  slow  and  leaves  a  weak  point  in  the  abdom- 
inal wall. 

But  these  disadvantages  are  more  than  equalled  by  the  greater 
security.  The  certain  hsemostasis  by  the  constriction  of  the  elastic 
ligature,  and  the  free  escape  of  secretions  from  the  pedicle,  remove 
the  twofold  danger  of  internal  hemorrhage  and  peritoneal  infection 
which  always  exists  when  the  stump  is  abandoned  in  the  abdomen, 
especially  when  the  uterine  cavity  has  been  opened. 

Neither  of  these  methods  should  be  absolutely  proscribed,  but  one 
or  the  other  should  be  selected  according  to  the  case.103 

The  dangers  of  the  intra-peritoneal  method,  which  is  evidently 
ideal  in  theory,  are:  Extreme  vascularity,  which  renders  control  of 
the  bleeding  impossible  without  the  application  of  so  many  sutures 
that  they  might  cause  mortification  and  septicemia ;  opening  of  the 
uterine. cavity,  which  would  give  access  to  germs  from  the  vagina;  in 
other  words,  there  is  danger  with  bleeding  and  with  hollow  pedi- 
cles :  they  are  to  be  treated  by  the  simple  or  the  mixed  extra-peri- 
toneal method,  which  is  designed  specially  to  guard  against  such 
dangers. 

For  other  cases  the  intra-peritoneal  method  may  be  chosen.  In 
case  of  suppurating  or  gangrenous  inflammation  of  the  tumor,  the 
extra-peritoneal  method  is  the  only  one  to  be  employed.104 

The  following  table  is  my  guide  in  the  selection  of  a  method  of 
abdominal  hysterectomy: 


Pedicle  solid ;  not  vaseu-  (  Ligatured  or  sutured  with  silk  or  catgut  and  aban- 
lar.  (  doned  in  Ihe  peritoneum — Schroder's  method. 


f  A 


Pedicle  hollow  ;    not  vas-  „ 
cular. 


Sufficient  length  ;    extra-peritoneal  treatment — 
Hegar's  method. 
B.     Insufficient    length ;      mixed    method — Wolfler- 
Hacker  or  Sanger. 


312 


CLINICAL   AND    OPEEATIYE    GYNAECOLOGY. 


Pedicle  very  vascular. 


No  pedicle  ;  tumor  inter- 
stitial or  submucous ; 
easily  enucleated. 


No  pedicle  ;  tumor  in  the 
pelvic  cellular  tissue  or 
included  in  the  broad 
ligament. 


f  A.  Sufficient  length  ;  extra-peritoneal  treatment— 
Hegar. 

B.  Insufficient  length  ;  mixed  treatment  with  elastic 
ligature — Sanger. 

C.  Very  short ;  intra-peritoneal  treatment  with  hid- 

den elastic  ligature— Olshausen  ;  or  total  hyster- 
ectomy— Bardenheuer. 

'A.  Lateral  portions  of  the  uterus;  very  vascular; 
supra-vaginal  hysterectomy  and  extra-perito- 
neal treatment — Hegar. 

B.  Anterior  or  posterior  surface  of  the  uterus;  not 

vascular  ;  enucleation,  suture  abandoned  in  peri- 
toneum— Martin. 

C.  The  same,  with  opening  of  uterine  cavity  ;  supra- 

vaginal hysterectomy,  extra-peritoneal  treat- 
ment— Hegar. 

A.  Small  tumor,  easily  enucleated  ;  decortication,  en- 
tire suture  of  the  pocket,  no  drainage. 

B.  Large  tumor,  easily  detached  from  uterus,  cavity 
large  or  bleeding  ;  decortication,  partial  resection, 
superficial  suture  of  the  pocket,  drainage  by  the 
vagina  (Martin)  or  by  the  abdominal  wound  ; 
iodoform  gauze  packing  ;  uterus  preserved. 

C.  The  same,  with  close  vascular  connections  to  part 

of  lateral  uterine  wall  ;  supra-vaginal  hysterec- 
tomy (for  treatment  of  pedicle  see  above) ;  suture 
and  drainage  of  the  pocket,  with  or  without  pack- 
ing. 


BIBLIOGRAPHY  AND  NOTES. 

1.  Por  literature  see  S.  Pozzi :  De  la  Valeur  de  l'Hysterot.,  Paris,  1875,  p.  5. 
.Hegar  and  Kaltenbach  :  Trait,  d.  Gyn.  Operat.,  French  trans.,  1885,  page  344.  P. 
Zweifel :  Die  Stielbehand.  bei  der  Myomect.,  etc.,  Stuttgart,  1888.  Caternault : 
Strasburg  Thesis,  1866. 

2.  Oilman  Kimball :  Boston  Med.  and  Surg.  Jour. ,  1855. 

3.  Koeberle" :  Documents  pour  Servir  l'Histoire  de  l'Extirp.,  etc.  Gaz.  me\L  de 
Strasbourg,  No.  2  et  seq.  The  first  hysterectomy  which  he  did  was  on  December 
19th,  1863. 

4.  P6an  :  Union  Me\L,  Dec.,  1889.  When  P6an  had  done  his  first  hysterectomy 
for  a  fibro-cystic  tumor,  with  complete  extirpation  of  both  uterus  and  ovaries, 
Koeberle"  had  already  had  nine  cases  with  four  cures. 

5.  Pean  and  Urdy  :  Hyst6rotomie,  de  l1  Ablation  Partiel.,  etc.,  Paris,  1873.  See 
also  Pean  :  Leconsde  Clin.  Chir.,  1876,  vol.  i.,  pp.  674  to  704,  and  1879,  vol.  ii.,  pp. 
808  to  830. 

6.  Hegar  and  Kaltenbach  :  Loe.  cit.,  French  trans.,  p.  345.  Hegar  is  wrong  in 
not  giving  to  Koeberle"  some  of  the  credit  which  he  gave  to  Pean.  Zweifel  does 
not  commit  the  same  injustice ;  loc.  cit.,  pp.  8  to  10. 

7.  Abdominal  hysterotomy  was  formerly  condemned  by  the  Acad,  de  M£d. 
at  Paris,  following  a  report  by  De  Marquay  on  the  works  of  Koeberle"  and  Pean. 
See  also  Boinet :  De  la  Gastrotomie,  etc.  Gaz.  hebdom.,  1873,  p.  117.  In  1875,  the 
examining  surgical  board,  presided  over  by  Prof.  Richet,  gave  as  one  of  their  sub- 


TREATMENT  OF  FIBROUS  TUMORS  OF  ABDOMINAL  EVOLUTION.     313 

jects  the  following,  which  fell  to  my  lot :  De  la  Valeur  de  l'Hysterotoinie  dans  le 
Traitement  des  Corps  Fibr.  de  l'Uterus.  "Abdominal  hysterotomy  is  an  operation 
which,  although  very  grave,  is  perfectly  justifiable  in  certain  cases,  and  deserves 
to  take  a  front  rank  in  surgery."  This  statement,  which  I  place  at  the  head  of  my 
conclusions,  seemed  at  the  same  time  very  audacious  (1875). 

8.  The  first  operation  where  elastic  ligature  was  employed  was  that  of  Klee- 
berg,  of  Odessa,  July  8th,  1876.  St.  Petersburg  Med.  Woch.,  September  24th  and 
October  6th,  1877.  Martin  recommended  provisional  elastic  ligature  in  1878,  at  the 
congress  in  Cassel.  Hegar  employed  it  for  permanent  ligature  of  the  pedicle. 
Dorff  :  Centr.  f.  Gyn.,  1880,  p.  265.  I  have  presented  a  case  to  the  Surgical  Soc, 
Paris,  November  28th,  1883.  Schroder  describes  his  method  of  treating  the  pedicle 
for  the  first  time  at  the  Cassel  congress,  1878 ;  at  the  Baden-Baden  congress  in 

1879,  and  finally,  at  the  Salzburg  congress  in  1881.  Arch.  f.  Gyn.,  Bd.  xv.,  page 
271,  and  xviii.,  p.  478.  Spencer  Wells  arrived  at  similar  results  independently  of 
Schroder :  Brit.  Med.  Jour.,  1880,  vol.  ii.,  p.  373;  describing,  at  the  48th  Congress 
of  the  Brit.  Asso.  of  Cambridge,  a  procedure  which  he  had  used  since  1878  :  ligature 
of  the  stump,  entire  or  in  separate  portions,  with  coaptation  of  the  peritoneum  on 
its  surface;  no  suture  of  the  uterine  mucous  membrane. 

9.  Kleeberg:  St.  Petersburg  med.  Woch.,  Sept.  24th  and  Oct.  6th,  1887. 

10.  A.  Martin  :  Naturforscherversanimlung  in  Cassel,  1878. 

11.  S.  Pozzi:  Bull,  de  la  Soc.  de  Chir.,  Nov.  28th,  1883,  and  Comptes  Rendus, 
1885,  p.  537. 

12.  Spiegelberg:  Arch,  fur  Gyn.,  Bd.  iv.,  p.  340. 

13.  Spencer  Wells.  Zweif  el:  Die  Stielbehandlung,  etc.,  p.  82.  The  operation  of 
Spencer  Wells  was  January  12th,  1863.  t 

14.  Martin  :   Loc.  cit.,  pp.  287  and  288;  and  Burkhardt :  Deutsche  med.  Woch., 

1880,  No.  27.  Czempin:  Zeit.  f.  Geb.  und  Gyn.,  Bd.  xiv.,  Heft  i.,  p.  233.  Gyn.  Soc. 
of  Berlin,  October,  1866.     Nagel:  Centr.  f.  Gyn.,  No.  31,  1886,  and  No.  40,  1886. 

15.  Freund :  Centr.  f.  Gyn.,  1888,'  No.  49. 

16.  T.  G.  Thomas:  Trans.  Amer.  Gyn.  Soc,  vol.  vi.,  p.  258,  1882. 

17.  Pean  and  Urdy:  Hysterotomie,  etc.,  p.  201. 

18.  Grammatikati  (St.  Petersburg)  has  demonstrated  by  experiments  on  rab- 
bits, and  the  examination  of  a  specimen  coming  from  a  patient  upon  whom  Lebedeff 
performed  hysterectomy  three  years  before,  that  one  ovary  continued  to  function- 
ate after  the  extirpation  of  the  other,  as  Well  as  that  of  the  uterus.  Centr.  f.  Gyn., 
1889,  No.  7.  Glaevecke's  researches  reach  the  same  conclusion.  Arch.  f.  Gyn.,  Bd. 
xxxv.,  Heft  i.        • 

19.  Hofmeier:  Man.  de  Gyn.  Operat.     Lauwer's  trans.,  Paris,  1889,  p.  253. 

20.  Czempin  :  Zeit.  f.  Geb.  und  Gyn.,  Bd.  xiv.,  Heft  i.,  p.  228. 

21.  Hofmeier :  Die  Myomotomie,  Stuttgart,  1884. 

22.  Olshausen:  Deutsche  Zeitsch.  f.  Chirurgie,  Bd.  xvi.,  1882. 

23.  A.  Martin:  Path,  und  Ther.  der  Frauenk.,  French  ed.,  1887,  p.  286. 

24.  Hegar  and  Kaltenbach  :  Gynak.  Oper.,  French  trans,  by  Bar,  p.  358. 

25.  G.  A.  Dirner :  Annals  of  Gyn.,  January,  1888. 

26.  Veit:  Centr.  f.  Gyn.,  1887,  No.  24. 

27.  Hegar  and  Kaltenbach  :  Die  operat.  Gyn.,  3d  ed.,  1886,  p.  506. 

28.  Czerny  :   Centr.  f.  Gyn.,  1879,  p.  519. 

29.  Hegar  and  Kaltenbach  :  Die  operat.  Gyn.,  1881,  p.  441. 

30.  Olshausen  :  Deutsche  Zeit.  f.  Chir.,  Bd.  xvi.,  p.  121,  and  klin.  Beitrage  zur 
Gyn.,  1884,  p.  86.  See  also  Hegar's  experiments  on  animals  in  Kasprzik  :  Berliner 
klin.  Wochenschrift,  1802,  No.  12.  Olshausen's  method  lately  adopted  in  Italy  by 
A.  Martinetti.     Ann.  di  Ost.  e  Gyn.,  No.  3,  1888. 

31.  Olshausen  :  Centr.  f.  Gyn.,  1888,  p.  389. 


314  CLINICAL   AXD    OPERATIVE    GYNAECOLOGY. 

32.  Ahlfeld  :  Bericht,  unci  Arbeit,  aus  der  Klin,  zu  Giessen,  1881  to  1882,  p.  286r 
Leipsic,  1883. 

33.  Thiersch  :  Centr.  f.  Gyn.,  1882,  No.  40,  p.  656. 

34.  Sanger  :   Centr.  f.  Gyn.,  1886,  No.  44. 

35.  Zweifel :   Die  Stielbehandlung  bei  der  Myomectomie,  1888. 

36.  Meinert :  Wien.  rued.  Woch.,  1885,  No.  42.  This  idea  seems  to  belong  to 
Porro  and  Wasseige  :  Centr.  f.  Gyn.,  No.  44, 1886.  See  also  Chrobak  :  Med.  Jahrb. 
d.  k.  k.  Gesell.,  Wien,  1888,  iii.,  p.  331.  Doleris  :  Soc.  Obst.  et  Gyn.  de  Paris,  April 
11th,  1889;  and  Rep.  Univ.  d'Obst.  et  de  Gyn.,  1889,  p.  355. 

37.  Nussbaum  :   Cited  by  Zweifel,  loc.  cit,,  p.  25. 

38.  Yulliet :  Revue  ni€d.  de  la  Suisse  Romande,  1885. 

39.  Zweifel :   Die  Stielbehandlung,  etc.,  p.  65.     Also  Centr.  f.  Gyn.,  1889,  No.  32. 

40.  Freund:  Centr.  f.  Gyn.,  1882,  page  481. 

41.  Wolfler:  Wien.  med.  Woch.,  No.  25,  1885,  and  von  Hacker:  Ibidem,  No.  48,. 
1885. 

42.  Sanger :  Centr.  f.  Gyn.,  No.  44,  1886.  H.  A.  Kelly  :  Auier.  Jour.  Obstetrics, 
April,  1889,  p.  375. 

43.  Billroth  :   Langenbeck's  Archiv,  Bd.  xxi.,  Heft  4. 

44.  Keith:  Edinburgh  Med.  Jour. ,  1885,  p.  939;  two  successes.  Polk:  Cited  by 
Yautrin.     Du  Trait.  Chir.,  1886,  p.  181;  one  successful  case  after  grave  peritonitis. 

45.  Martin  :   Centr.  f.  Gyn.,  1889,  No.  40. 

46.  Crofford:  Anier.  Jour.  Obst.,  May,  1889. 

47.  Bardenheuer  :   Centr.  f.  Gyn.,  1882,  No.  22. 

48.  Martin  :  Path,  und  Ther.  der  Frauenk.,  p.  290. 

49.  Hegar  and  Kaltenbach  :  Lpc.  cit.,  p.  498,  3d  edition. 

50.  Sanger  :  Zur  Oper.  von  Cervixmyomen  durch  die  Laparotomie.  Gyn.  Soc. 
of  Leipsic.     Centr.  f.  Gyn.,  1889,  No.  12. 

51.  Terrier  :  Bull,  de  la  Soc.  de  Chir.,  1885,  p.  868. 

52.  H.  A.  Kelly  :   American  Journal  of  Obstetrics,  January,  1886,  p.  44. 

53.  S.  Pozzi:  Bull,  de  la  Soc.  de  Chir.,  December  18th,  1889. 

54.  Kiister:   Centr.  f.  Gyn.,  1884,  No.  1. 

55.  G.  A.  Dirner:   Centr.  f.  Gyn.,  1887,  Nos.  7  and  8. 

56.  Olshausen:  Handbuch  der  Frauenk.,  ii.,  pp.  586,  751.  S.  Pozzi:  Annal.  de 
Malad.  des  Organ.  Genito-urin. ,  May  1st,  1883.  J.  Reverdin  :  Ibid.,  January,  1886. 
Sanger  :  Second  Cong,  of  the  German  Gyn.  Soc,  Halle,  May  25th,  1888.  Leopold  : 
Ibid.  Report  of  three  cases  of  Lucas-Championniere  in  Ricard.  Gaz.  des  Hopit., 
March  2d,  1889.  Two  of  these  during  operation  for  radical  hernia,  the  other  in 
supra-pubic  lithotomy.  S.  Pozzi :  Bull,  de  la  Soc.  de  Chir.,  April  10th  and  Decem- 
ber 18th,  1889. 

57.  Kustner:  Deutsche  med.  Woch.,  1888,  No.  17. 

58.  U.  Wiercinsky:  Centr.  f.  Gyn.,  1889,  No.  45. 

59.  Hofmeier :  Zeit.  f.  Geb.  und  Gyn.,  Bd.  xi.,  Heft  2,  p.  366. 

60.  Cohnheim  :   Yorles.  uber  allg.  Path.,  Berlin,  1882,  Bd.  i.,  p.  473. 

61.  Ungar:  Yierteljahrschrift  f.  gericht,  Med.,  47  Jahrgang. 

62.  Oberlander:  Deutsche  Zeits.  f.  pract.  Med.,  18~8,  p.  37.  Konig:  Centr.  fur 
Chir.,  1882,  Nos.  7  and  8.  Ktister:  Berl.  klin.  Woch.,  1878,  No.  48.  Sanger  :  Berl. 
klin.  Woch.,  No.  22. 

63.  Olshausen :  Centr.  f.  Gyn.,  1888,  No.  10. 

64.  Landau  :  Centr.  f.  Gyn.,  1889,  No.  11. 

65.  A.  StrUmpell:  Lehrb.  der  spec.  Path,  und  Ther.,  1884,  Band  ii.,  Abth.  ii.„ 
p.  305. 

66.  L.  Lewin  :  Lehrb.  der  Toxicol.,  1885,  p.  404. 

67.  Pean  :  Lecons  de  Clin.  Chirurg.,  1879,  p.  309. 


TREATMENT  OF  FIBROUS  TUMORS  OF  ABDOMINAL  EVOLUTION.     315 

68.  A.  Obolinski:  Berlin,  klin.  Woeh.,  1889,  No.  12.      ■ 

69.  Bode  and  Leopold  :   Centr.  f.  Gyn.,  1889,  No.  30. 

70.  S.  Pozzi:  De  la  Valeur,  etc.,  1875;  119  cases  with  77  deaths;  64  per  cent. 
Letousey:  HysteYec.  sus-vag.,  etc.,  1879;  84  cases;  36  deaths;  43  per  cent.  Gusse- 
row  :  Die  Neubild.,  etc.,  from  1878  to  1885;  533  cases;  185  deaths  or  34.8  per  cent. 
Vautrin  :  173  cases;  68  deaths;  39  per  cent.     Paris  Thesis,  1886. 

71.  P.  Wehmer:  Zeits.  f.  Geb.  und  Gyn.,  Bd.  xiv.,  p.  134,  1887. 

72.  Gusserow  :  Zeit.  f.  Geb.  und  Gyn.,  Bd.  xiv.,  p.  134. 

73.  P.  Wehmer:  Loc.  cit. 

74.  Martin  :   Path,  und  Ther.,  etc.,  2d  ed.,  p.  287,  1887. 

75.  Olshausen  :  Klin.  Beitr.  zur  Geb.  und  Gyn. 

76.  Spencer  Wells:  Diagnosis  and  Surgical  Treatment  of  Abdom.  Tumors. 

77.  Schroder:  Handb.  d.  Frauenk.,  1886. 

78.  Tauffer,  in  Dirner:  Centr.  f.  Gyn.,  1887,  Nos.  7  and  8. 

79.  Bantock  :   Brit.  Med.  Jour.,  Aug.,  1882. 

80.  Hegar  :  Operat.  Gyn.,  4th  edition. 

81.  Kaltenbach,  in  P.  Wehmer:  Loc.  cit.  Keith:  Contributions  to  Surgical 
Treatment  of  Abdomen  after  Wehmer. 

82.  Pean,  cited  by  Schroder:  Mai.  des  Org.  Geuit.,  etc.,  French  ed.,  p.  275. 

83.  Tauffer,  in  Dirner  :  Loc.  cit. 

84.  Spencer  Wells  :  Loc.  cit. 

85.  Lawson  Tait,  cited  by  Wehmer  :  Loc.  cit. 

86.  Thornton:  Ibidem. 

87.  Braun:  Cases  partly  published.  Wiener  med.  Woeh.,  1884,  No.  22,  and 
1887,  Nos.  22-25,  and  partly  communicated  to  Zweifel. 

88.  Fehling:  Wtlrtemberg.  arzt.  Correspondenzblatt,  1887,  Nos.  1-3. 

89.  Gusserow:  Charit6-Annalen,  9th  year,  and  by  letter  to  Zweifel. 

90.  Kehrer,  Leopold,  Saxinger,  Schultze,  Werth :  Unpublished  cases  reported 
to  Zweifel. 

91.  Schauta  :  Two  of  these  cases  have  been  published  in  Gyn.  Causuistik. 
Wiener  med.  Blatter,  1886. 

92.  Braun:   Wiener  med.  Woeh.,  1884. 

93.  Dohrn,  Kehrer,  Saxinger,  Schauta,  Schultze,  Werth,  Winckel :  Unpublished 
cases  reported  to  Zweifel. 

94.  Fehling:  Loc.  cit.  (88). 

95.  Gusserow  :  Charit^-Annalen,  9th  year,  by  letter  to  Zweifel. 

96.  Leopold  :  Six  published  cases  and  the  rest  by  letters  to  Zweifel. 

97.  Runge  :  St.  Petersburg  med.  Wochensch.,  1885,  No.  51.  Ibid.,  1887,  No.  19. 
Centr.  f.  Gyn.,  1887,  No.  15. 

98.  Tauffer  :   Centr.  f.  Gyn.',  No.  20. 

99.  Fritsch:  Volkmann's  Sammlung  klin.  Vortr.,  1889,  No.  339. 

100.  Albert :  Wien.  med.  Presse,  1888,  No.  13,  and  1889,  No.  2. 

101.  C.  Braun  :  Wiener  med.  Woeh.,  1887,  Nos.  22  and  25. 

102.  Hegar,  cited  by  Nicaise  :   R6pert.  Univ.  d'Obst.,  etc.,  1889,  p.  503. 

103.  S.  Pozzi:   Cong.  Fran,  de  Chir.,  1st  session.     Comptes  Rendus,  p.  537. 

104.  Odebrecht:  Zeit.  f.  Geb.  und  Gyn.,  Bd.  xv.,  Heft  i.  A.  Sippel:  Centr.  f. 
Gyn.,  1888,  No.  44. 


OHAPTEE    XII. 
CASTRATION   FOR  FIBROMA. 

Clinical  experience  has  long  demonstrated  that  the  cessation  of 
the  sexual  life  in  women  is  followed  by  a  remarkable  diminution  in 
the  symptoms  caused  by  fibrous  tumors;  the  bleeding  stops  and  the 
tumor  atrophies.  To  hasten  the  appearance  of  this  favorable  period 
we  may  produce  an  artificial  menopause  by  removal  of  the  ovaries. 

The  term  castration  has  given  rise  to  much  discussion ;  it  should  be 
reserved  for  ablation  of  healthy  ovaries  to  secure  a  functional  modifi- 
cation.1 Hegar  applies  the  term  to  any  removal  of  ovaries,  normal  or 
diseased,  which  do  not  "  form  a  notable  tumor."  2  This  definition  is 
insufficient,  for  then  the  operation  would  be  called  castration  when 
performed  for  a  cyst  of  the  size  of  the  fist,  and  ovariotomy  when  it 
was  of  the  size  of  the  head.  Battey  and  the  Americans  call  castra- 
tion "normal  ovariotomy"  and  "oophorectomy."  It  is  not  well  to 
thus  confound  operations  where  the  adnexa  are  removed,  as  the  cen- 
tres of  morbid  reflexes,  hemorrhagic  or  painful,  with  those  where  it 
is  done  for  a  pathological  condition  diagnosed  before  the  abdomen  is 
opened,  as  in  salpingo -oophorectomy,  generalized  by  Lawson  Tait. 
The  term  castration  is  then  to  be  used  for  the  ablation  of  adnexa  re- 
puted normal,  and  it  may  be  haemostatic  (Trenholme,  Hegar)  or  anal- 
gesic (Battey).  Oophorectomy  designates,  like  salpingo-oophorectomy, 
extirpation  of  inflamed  adnexa  in  salpingitis  or  ovaritis.  Thus  con- 
fusion is  avoided. 

Castration  for  painful  dysmenorrhea  was  done  in  1872  at  almost 
the  same  time  by  Hegar  and  Battey,3  and  surgeons  had  begun  to  famil- 
iarize themselves  with  the  operation  when  Trenholme 4  published,  in 
1876,  the  first  known  case  of  castration  for  uterine  myoma ;  a  month 
after,  Hegar  performed  it  with  the  same  object.  There  is  no  doubt 
that  Hegar  did  not  know  of  the  operations  of  Battey  and  Trenholme 
when  he  conceived  and  executed  his,  although  they  had  already  been 
published,5  and  it  is  largely  due  to  his  writings  and  to  those  of  his 
pupil 6  Wiedow  that  the  operation  has  become  general.     In  England, 


CASTRATION   FOR   FIBROMA.  817 

Lawson  Tait,7  and,  in  France,  Duplay,8  Tissier,9  and  Segond 10  have 
promoted  it. 

It  is  not  easy  to  formulate  exactly  the  indications  for  this  opera- 
tion. Hegar  "  recommends  it  in  nearly  every  case  in  preference  to 
hysterectomy,  the  graver  operation,  holding  himself  ready  to  perform 
the  second  if  the  first  is  not  sufficient;  he  mentions  the  different 
forms  of  fibrous  tumor  for  which  he  has  successively  practised  it,  and 
finds  that  there  are  no  exceptions.  Thornton12  has  also  had  good 
results  in  cases  of  fibro-cyst.  There  is  no  doubt,  however,  that  there 
are  cases  where  the  operation,  though  easy  of  performance,  is  danger- 
ous from  its  consequences,  and  there  are  others  where  the  danger 
arises  from  the  inherent  difficulties  of  its  accomplishment. 

In  the  first  class  belongs  castration  for  large  solid  or  fibro-cystic 
tumors ; 13  for  by  the  obliteration  of  the  vessels,  both  blood  and 
lymphatic,  which  it  causes  it  may  produce  formidable  and  rapid 
changes  in  the  fibrous  mass.  There  may  be  oedema,  as  the  result  of 
the  venous  stasis  or  as  the  first  stage  of  mortification,  or  embolism 
following  thrombosis  when  the  broad  ligaments  contain  large  vessels. 
The  operation  may  also  be  dangerous  from  the  risk  of  immediate 
hemorrhage  when  there  are  very  vascular  adhesions  or  when  the 
alae  of  the  broad  ligaments  are  effaced,  as  is  the  case  with  some  intra- 
ligamentous tumors. 

These  considerations  govern  the  operative  indications,  which  may 
be  thus  stated :  Castration  should  be  employed  in  every  case  where 
its  performance  is  less  grave  than  hysterectomy,  and  where  the  latter 
is  not  especially  indicated  by  compression  phenomena. 

With  pedicled  fibroma  myomectomy  is  to  be  preferred  for  two 
reasons — first,  because  it  is  the  less  dangerous  operation;  and,  second, 
because  with  this  form  of  the  tumor  the  bleeding  is  not  the  most 
important  symptom,  and  it  is  against  hemorrhage  that  castration  is 
chiefly  directed. 

Interstitial  fibroma  with  abdominal  evolution  and  of  small  or 
medium  size  may  be  treated  by  castration  if  the  only  troublesome 
symptom  is  the  loss  of  blood ;  and  the  same  is  true  of  pelvic  and 
intra-ligamentous  tumors  at  the  beginning  of  their  evolution. 

Profound  ansemia  would  be  a  strong  indication  for  removal  of  the 
ovaries  rather  than  of  the  uterus. 

Castration  is  therefore  contra-indicated  with  very  large  tumors, 
from  the  danger  of  oedema  and  mortification;  with  tumors  of  small 
size   which    give  rise  to   compression   symptoms;    with  fibro-cystic 


318  CLINICAL   AND   OPEEATIVE   GYNECOLOGY. 

tumors,  from  the  relative  benignancy  of  hysterectomy  and  the  rapid 
course  of  the  neoplasm ;  and,  lastly,  with  telangiectatic  tumors,  from 
the  danger  of  thrombosis.  These  are  the  'elements  which  direct  the 
choice  of  the  operation,  but  it  is  difficult  to  formulate  them  in  a  defi- 
nite manner  before  the  abdomen  is  opened.  As  certain  authors  have 
truly  said,  castration  always  begins  as  an  exploratory  incision,  after 
which  the  connections  of  the  tumor  may  be  exactly  defined  and  the 
dangers  of  operation  settled. 

It  is  then  either  an  operation  of  choice,  decided  upon  before  the 
first  incision  is  made,  or  one  of  necessity,  undertaken  during  the 
operation,  when  the  opening  of  the  abdomen  has  demonstrated  that 
the  risk  of  the  premeditated  hysterectomy  would  be  too  great  or  that 
extirpation  of  the  ovaries  is  both  possible  and  of  evident  advantage. 

Terrillon  has  attempted  to  make  the  dimensions  of  the  uterine  cav- 
ity a  precise  and  easily  appreciated  criterion  for  the  performance  of 
castration.  According  to  him,  when  the  cavity  measures  from  11  to 
14  cm.  this  operation  gives  the  best  results ;  but  when  it  is  from  18  to 
20  or  23  cm.  there  are  few  chances  of  success;  he  advises,  therefore, 
that  his  flexible  hysterometer  (with  a  dial)  be  always  employed  be- 
fore operating.  In  other  words,  this  advice  merely  reiterates  the 
danger  of  ablation  of  the  ovaries  in  cases  of  large  interstitial  tumors, 
one  of  whose  signs  is  great  increase  of  the  uterine  cavity.  It  is  bet- 
ter to  make  the  diagnosis  without  the  aid  of  the  sound,  for,  as  AVinter 
has  shown,14  it  may  carry  into  the  uterus  the  germs  which  exist  nor- 
mally in  the  cervix,  and  thus  produce  auto-infection  of  the  patient. 
The  use  of  a  rigid  instrument  is  dangerous  from  still  another  cause 
— it  may  produce  a  false  passage  on  account  of  the  distortion  due 
to  the  tumor  and  the  softness  of  the  mucous  membrane;  suppura- 
tion of  the  myoma  and  death  have  thus  followed  such  an  exploration.15 

Operative  Teclmique. — The  best  time  to  perform  the  operation 
is  during  the  week  after  the  menses.  The  preparation  for  it  and  the 
rules  for  the  abdominal  incision  are  the  same  as  in  every  laparatomy. 
Hegar  advises  always  to  palpate  the  ovaries  and  make  sure  of  their 
exact  position  before  making  the  incision,  but,  while  a  useful  precau- 
tion, it  is  not  always  possible  to  acquire  positive  ideas  upon  this  point 
before  opening  the  abdomen. 

There  are  three  ways  of  reaching  the  ovaries — by  the  median  line, 
the  lateral  aspect  of  the  abdomen,  and  the  posterior  cul-de-sac  of  the 
vagina ;  the  first  is  the  only  really  practical  method  in  the  great  ma- 
jority of  castrations  for  myoma. 


CASTRATION    FOR   FIBROMA.  319 

* 

The  lateral  incision  presents  theoretic  advantages,  because  we  come 
directly  upon  the  ovary  which  is  often  thrust  outward  by  the  pro- 
jecting tumor;  Hegar  has  employed  it,  following  the  example  of 
veterinary  surgeons.  But  it  seems  to  have  been  abandoned  owing  to 
the  real  disadvantages  which  it  possesses — the  necessity  of  a  double 
wound,  the  strong  retraction  of  the  lips,  the  great  vascularity  of  the 
tissues  in  this  region,  etc.  It  would  be  only  in  the  case  of  a  tumor  of 
great  size  with  much  lateral  displacement  that  this  incision  would  be 
necessary,  and  it  is  in  just  those  cases  that  castration  is  a  dangerous 
operation,  not  to  be  deliberately  proposed. 

The  vaginal  incision  finds  its  proper  indication  in  the  case  of  the 
operation  which  I  have  called  the  analgesic  (Battey),  performed  in  the 
absence  of  tumor  and  when  we  can  determine  the  prolapse  of  the 
ovary  into  the  pouch  of  Douglas;  but  it  is  altogether  unsuitable 
when  there  is  a  fibroma  which  has  lifted  the  pelvic  tissues  above  the 
level  of  the  superior  strait.  Moreover,  there  is  danger  by  vaginal  touch, 
of  confounding  a  small  lobulated  fibroma  with  a  prolapsed  ovary, 
and,  lastly,  there  is  the  danger  of  hemorrhage  from  dilated  vessels  of 
the  broad  ligaments — a  danger  which  is  here  of  especial  importance 
owing  to  the  depth  at  which  we  are  obliged  to  operate. 

Oophorectomy  by  a  Median  Incision — First  Step — Opening  the 
Abdomen. — The  incision  is  made  at  a  greater  or  less  distance  from  the 
umbilicus  according  to  the  height  to  which  we  supxjose  that  the  tumor 
has  carried  the  adnexa,  and  should  not  extend  more  than  about  8  cm., 
giving  just  room  enough  to  pass  one  or  two  fingers.  As  soon  as  the 
peritoneum  is  reached,  great  caution  is  needed ;  a  small  incision  is 
made  in  it  with  a  bistoury  held  fiat,  and  into  this  is  passed  a  grooved 
director,  and  the  incision  is  finished ;  thus  we  avoid  wounding  the  in- 
testine or  the  surface  of  the  tumor,  on  which  any  scratch  might  cause 
copious  bleeding. 

Second  Step — Finding  and  Remomng  thie  Ovary. — While  the 
mesentery  and  intestine  are  held  out  of  the  way  by  a  flat  gauze-sponge, 
the  index  and  middle  fingers  of  the  right  hand  are  .passed  deeply 
through  the  wound  and  down  upon  the  fundus  of  the  uterus  to  search 
for  the  ovary ;  as  soon  as  it  is  found,  it  is  drawn  with  the  end  of  the 
tube  out  of  the  wound  between  the  two  fingers ;  at  the  same  time  an 
assistant  holds  the  lips  of  the  incision  together.  To  ensure  a  stronger 
hold  upon  the  ovary,  a  pair  of  forceps  may  be  used  instead  of  the 
fingers,  and  special  forms  of  the  instrument  have  been  devised  for 
this   purpose,   but  a  long  and   somewhat  curved  pair  is  all  that  is 


320  CLINICAL  AND   OPERATIVE   GYNAECOLOGY. 

needed,  passed  beneath  the  ovary  and  the  pavilion  of  the  tnbe.  A 
blunt  needle  with  a  double  thread  is  then  used  to  tie  oil  these  parts, 
and  for  this  purpose  I  am  accustomed  to  employ  Lawson  Tait's  knot 
(p.  54,  Figs.  34  to  37),  which  is  quickly  tied  and  leaves  but  one  knot 
within  the  peritoneum ;  but  if  the  pedicle  is  very  large,  it  is  better  to 
tie  it  with  two  crossed  ligatures.  It  is  well  to  include  the  tube  in  this 
ligature,  for  it  is  frequently  the  seat  of  chronic  inflammation,  and  its 
complete  removal  contributes  much  to  the  cure  of  both  pain  and  hem- 
orrhage. 

If  the  pedicle  is  very  short,  it  is  advisable  to  add  to  this  ligature 
in  mass  (which  may  slip)  separate  ligatures  for  the  vessels,  which 
are  to  be  carefully  sought  upon  the  surface  of  the  section.  We 
should  also  assure  ourselves  that  the  ligature  has  been  placed  below 
the  ovary,  and  that  no  portion  of  the  organ  has  escaped.  The  crushed 
and  flattened  form  of  the  ovary  is  very  remarkable  in  certain  cases  of 
fibroma.  As  an  additional  measure  of  safety,  I  prefer,  with  Hegar,  to 
cauterize  the  pedicle  "with  the  thermo-cautery,  producing  a  thorough 
destruction  of  the  tissues;  if  there  remains  any  vestige  of  the 
ovary,  it  will  thus  be  sufficiently  modified  to  ensure  its  absorption. 
The  operation  is  not  successful  if  the  least  part  of  the  organ  is  left 
to  become,  as  P.  Miiller 16  has  shown,  the  seat  of  new  cystic  for- 
mations. 

This  cauterization  may  be  performed  on  the  flat  surface  of  a  for- 
ceps furnished  with  an  non-conducting  plate  of  ivory ;  Hegar  has  given 
to  this  instrument  a  double  curvature,  which  is  very  convenient  when 
the  pedicle  is  deeply  situated  (Fig.  165).  Instead  of  cutting  the  part 
away  with  the  cautery,  which  is  very  slow,  I  prefer  to  use  it  only 
when  the  section  is  completed  with  the  scissors,  leaving  a  sma]l  stump, 
which  I  gradually  dry  up  with  successive  applications  of  the  cautery 
carried  to  a  dull  red  heat.  This  cauterization  is  at  the  same  time 
antiseptic,  haemostatic,  and  destructive  of  the  last  portions  of  the  ovary. 
When  the  ovary  can  be  readily  seized,  I  do  no  use  the  forceps,  but 
grasp  the  organ  with  the  left  hand,  cut  off  about  three-quarters  of  the 
pedicle  with  the  scissors,  at  the  distance  of  1  cm.  from  the  ligature; 
then,  holding  the  pedicle  by  the  uncut  portion,  I  cauterize  the  sur- 
face of  the  section  with  the  thermo-cautery,  and  as  the  last  thing  com- 
plete the  division  of  the  pedicle  with  it. 

The  ends  of  the  ligatures  should  not  be  cut  until  it  is  sure  that 
there  is  no  more  oozing  and  that  the  threads  are  we.ll  placed;  but  if 
they  are  left  to  the  end  of .  the  operation,  with  the  idea  of   a  final 


CASTRATION    FOR   FIBROMA. 


321 


supervision,  they  may  do  harm  by  the  traction  which  is  exerted 
upon  them. 

The  second  ovary  is  removed  in  the  same  manner. 

If  the  small  incision  which  I  have  recommended  is  not  large  enough, 
it  would  be  better  to  enlarge  it  either  above  or  below  rather  than  to 
use  much  force ;  but  it  is  dangerous  to  carry  this  increase  too  far,  or 
to  divide  the  insertion  of  the  rectus  muscle,  as  has  been  advised.  If 
the  intestines  are  much  in  the  way  the  patient  should  be  put  in 
Trendelenburg's  position,  which  causes  them  to  fall  toward  the  dia- 
phragm (see  pp.  87  and  89). 

Tamponing  the  vagina  or  rectum  to  bring  the  ovaries  out  of  the 
lower  pelvis  is  a  procedure  which  is  rarely  needed  in  the  removal  of 


Fig.  165. — Hegar's  Forceps  for  Cauterising  the  Pedicle  r>*  Castratiox.    A,  Upper  surface:  B, 
under  surface  vrith  ivory  plate. 


abnormal  organs,  for  they  are  then  more  often  found  above  than 
below  the  superior  strait. 

Evisceration  or  the  temporary  extraction  of  a  portion  of  the  intes- 
tine is  at  times  advantageous,  but  it  is  so  dangerous  that  I  think  it 
should  be  kept  as  a  last  resort,  for  it  is  difficult  to  replace  the  intes- 
tines into  the  cavity  of  the  abdomen  which  becomes  sensibly  dimin- 
ished by  the  operation  while  they  become  distended  with  gas.  And, 
finally,  the  paralysis  which  sometimes  follows  their  exposure  may. 
in  spite  of  all  precautions  which  can  be  taken,  end  in  septicaemia 
from  the  absorption  of  intra-mtestinal  toxic  substances.17 

In  any  case  we  should  not  imprudently  bring  the  tumor  out  of  the 
abdomen ;  it  becomes  congested  and  swollen  and  very  difficult  of  re- 
introduction,  which  exposes  to  the  risk  of  thrombosis  and  embolism ; 

21 


322 


CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 


but  there  is  no  danger  in  turning  it  upon  its  axis  in  the  abdomen  to 
make  the  adnexa  more  accessible. 

Adhesions  between  the  ovary  and  tube  and  adjacent  parts  should, 
on  account  of  the  large  development  of  the  venous  circulation  which 
occasionally  accompanies  fibromata,  be  detached  only  with  the  great- 
est caution  and  as  much  as  possible  under  the  control  of  the  sight. 

When  the  broad  ligament,  especially  the  portion  attached  to  the 
ovary,  is  very  short,  it  forms  an  insurmountable  obstacle  to  the 
success  of  the  operation;  the  ligatures  slip  and  it  is  impossible  to 
form  a  pedicle.  In  one  such  case  Hegar  terminated  the  operation  by 
hysterectomy  in  order  not  to  lose  the  patient  by  hemorrhage.     The 


Fig.  166.— Castration.    The  tube  and  the  ovary  are  seized  with  Hegar's  forceps;  the  ligature  is 
passed  around  the  pedicle  by  a  blunt  needle. 

bleeding  may  be  arrested  by  a  strong  suture  made  like  a  hem  in  sew- 
ing, or,  after  the  example  of  Hegar,18  an  elastic  ligature  may  be  ap- 
plied to  the  ovarian  pedicle. 

Some  surgeons  attribute  great  importance  to  ligature  of  the  tubo- 
ovarian  vessels  even  without  removal  of  the  ovary,  believing  that  it 
causes  fatty  degeneration  of  the  ovary  or  directly  modifies  the  vital- 
ity of  the  uterus  and  favors  atrophy  of  the  tumor.19  Although  such 
an  "  atrophy  ligature  "  (Antal)  may  be  employed  as  a  necessity  when 
removal  offers  great  difficulties  or  dangers,  it  would  certainly  be  a 
mistake  to  advocate  it  as  a  matter  of  choice.  Terrier  is  its  avowed 
partisan,  and  Segond20  accepts  it  as  an  expedient  to  diminish  the 
number  of  merely  exploratory  laparatomies ;  but  this  "expedient" 


CASTRATION   FOR   FIBROMA.  'S23 

does  not  appeal  to  me,  and,  while  its  usefulness  is  questionable,  it 
does  not  seem  to  me  harmless. 

It  seems  to  me  much  better  to  remove  both  ovaries,  close  the  ab- 
domen as  soon  as  possible,  and  not  wait  to  perform  ligation  of  a  vessel 
which  shall  produce  a  theoretical  atrophy  by  lessening  the  afflux  of 
blood.  It  has  been  claimed,  however,  that  by  this  method,  unilateral 
castration  has  in  certain  cases  an  influence  upon  the  development  of 
a  myoma  which  is  on  one  side  of  the  uterus.  Removal  of  the  ovaries 
is  rational  only  when  performed  on  both  sides  to  produce  an  artificial 
menopause. 

Unilateral  castration  appears  to  have  had  its  rise  from  the  neces- 
sities of  operation  rather  than  from  theoretic  conceptions ;  the  latter 
have  come  afterward  to  make  it  legitimate.  Sims,  Battey,  and  their 
imitators  are  plainly  following  a  mistaken  path  in  praising  it. 

Third  Step — Toilet  of  the  Peritoneum  and  Suture. — This  toilet 
is  usually  very  rapidly  made,  except  when  there  has  been  a  rupture 
of  a  coexisting  cyst  in  the  tube  or  broad  ligament.  The  threads 
passed  through  the  abdominal  walls  at  the  beginning  of  the  opera- 
tion are  removed,  a  continuous  catgut  suture  of  the  peritoneum  is. 
made,  and  then  of  the  muscular  £)lanes,  ending  with  interrupted 
suture  of  the  integuments  by  strong  silk  and  a  few  supplementary 
sutures  of  fine  catgut  (Plate  VI.,  Fig.  5).  If  the  lips  of  the  wound  are 
contused,  it  is  well  to  leave  a  drainage  tube  between  the  muscles  and 
the  skin,  which  may  be  withdrawn  at  the  end  of  twenty-four  hours. 
Drainage  of  the  abdominal  cavity  is  not  employed  unless  there  has 
been  an  effusion  of  pus  (pyo-salpinx),  or  unless  the  operation  has  been 
very  long  and  laborious ;  in  the  first  case  the  peritoneum  should  be 
washed  out  with  hot  water. 

After-treatment. — If  there  is  a  metrorrhagia  a  short  time  after 
the  operation,  hot  vaginal  douches  and  hypodermics  of  ergotine  are 
to  be  employed.  Strong  compression  of  the  abdominal  wall  must  be 
kept  up,  on  account  of  the  presence  of  the  tumor  and  the  intestinal 
paresis  which  always  follows  a  laparatomy.  It  is  well  also  to  keep 
the  patient  in  a  slanting  position,  by  raising  the  pelvis,  so  as  to  cause 
the  intestines  to  occupy  the  upper  part  of  the  abdomen.  The  second 
day  a  laxative  enema  should  be  administered  to  evacuate  the  gas. 

Mortality  and  Results  of  the  Operation. — Conforming  to  the 
method  which  I  have  adopted,  I  give  the  results  obtained  by  surgeons  of 
the  greatest  authority  on  this  special  subject.  Hegar 21  in  55  cases  had  6 
deaths — 11^ — of  which  number    5  were  from  septicaemia  (one  case 


324  CLINICAL   A^D   OPERATIVE   GYNAECOLOGY. 

due  to  infection  before  operation),  and  16  cases,  or  29$,  presented 
complications  of  greater  or  less  gravity,  such  as  3  mild  cases  of  peri- 
tonitis, 7  of  abscess,  4  of  thrombosis  of  the  lower  extremity,  1  of 
pneumonia,  and  1  of  vesical  catarrh:  complete  success  in  33  cases. 
Deducting  from  these  55  cases  the  6  deaths,  and  also  12  which  were 
still  too  recent  and  9  where  there  was  a  simultaneous  extirpation 
of  a  large  pedicled  fibroma,  there  remain  24  cases  of  castration  op- 
erated on  more  than  a  year  and  a  half.  The  following  are  the  results 
as  regards  cure: 

(a)  Hemorrhage. — In  20  cases  there  was  immediate  cessation.of  the 
bleeding ;  in  4  cases  cessation  after  certain  irregular  losses ;  in  1  case 
persistence  of  irregular  metrorrhagia ;  in  1  case  temporary  menopause, 
then  hemorrhage  and  fibro-cystic  development  of  the  tumor ;  and  in  1 
case  menopause,  then  hemorrhage  with  beginning  enucleation  of  the 
tumor,  which  was  finally  extirpated  by  Fehling. 

(b)  Tumor.— In  the  same  series  of  28'  cases  there  were  22  cases 
with  diminution  of  the  tumor;  3  cases  with  no  change;  1  case,  dimi- 
nution doubtful;  1  case,  appearance  of  a  fibro-cystic  tumor;  1  case, 
secondary  enucleation. 

Thus  it  is  plain  that  the  menopause  and  atrophy  of  the  tumor  are 
not  necessarily  correlative ;  the  bleeding  may  cease  without  any  dim- 
inution in  the  size  of  the  fibroma,  but  this  is  the  exception.  Two 
of  Hegar's  cases  became  obese ;  another  presented  five  years  after  the 
operation,  which  had  been  followed  by  the  menopause  and  retraction 
of  the  tumor,  a  focus  of  parametritis  coming  from  a  blow  upon  the 
pedicle ;  and  another  was  cured  of  a  reflex  chronic  cough.22 

The  care  with  which  these  cases  have  been  observed,  the  absolute 
security  of  the  name  of  Hegar,  give  to  these  figures  a  peculiar  in- 
terest; it  is  necessary,  however,  to  know  the  collected  statistics  of 
different  authors.  The  following  are  taken  from  Tissier's  recent 
series : 

In  171  operations,  25  deaths — 14.6$.  The  causes  of  death  were:  In 
12  cases  septicemia;  in  1  case,  embolism  of  pulmonary  artery;  in  1 
case,  cardiac  debility,  with  death  eleven  days  after  the  operation; 
in  9  the  result  was  undetermined. 

(a)  Results  as  to  hemorrhage  in  146  cases:  In  89,  complete  cessa- 
tion; in  21,  menopause  after  a  period  of  irregular  losses;  in  10;  return 
of  the  menses  after  a  short  respite.  In  this  list  are  included  one  case 
of  unilateral  operation  and  one  of  ligature  of  one  ovary ;  in  three,  the 
statement  is  simply  that  the  patient  was  cured. 


CASTRATION    FOR    FIBROMA.  325 

(b)  As  regards  the  tumor  (146  cases):  Nine  times,  no  change;  OG 
times,  rapid  diminution;  71  times,  no  note  on  the  point. 

Wiedow 2S  has  published  statistics,  made  with  great  care,  where  no 
patient  is  reported  under  a  year  after  operation.  There  are  56  cases, 
which  agree  pretty  well  with  those  of  Hegar  just  given.  In  39  there 
was  a  menopause  with  atrophy  of  the  tumor;  in  5  the  menopause 
alone  is  noted ;  in  5  there  were  small  irregular  losses ;  in  1  there  were 
menopause  for  three  months,  then  partial  enucleation  of  the  tumor, 
which  was  finished  by  the  surgeon;  in  1,  amenorrhcea  followed,  then 
return  of  the  menses  with  atrophy  of  the  tumor;  in  1  there  were 
small  losses  lasting  a  day  after  amenorrhceal  intervals  of  three  months 
(no  note  as  to  the  tumor) ;  in  3  after  menopause  and  atrophy  for  two 
years  there  was  return  of  the  hemorrhage  and  development  of  the 
tumor,  which  became  fibro-cystic  in  1  case. 

Lawson  Tait 2i  has  performed  castration  for  fibroma  262  times,  with 
a  mortality  which  he  imts  at  1.23$;  but  we  have  no  precise  informa- 
tion as  to  the  curative  effects  of  his  operations.  Fehling  has  a  series 
of  8  cases  with  no  death ; 25  in  5  the  menopause  was  permanent ; 
in  2,  there  were  irregular  hemorrhages  at  the  end  of  one  and  two 
years;  in  all,  the  tumor  diminished  in  size.  Prochownik a6  in  12  cases 
had  no  deaths;  the  tumors  atrophied,  and  the  return  of  irregular  hem- 
orrhages was  exceptional.  Bouilly 27  has  performed  castration  8  times 
for  fibroma,  with  excellent  results;  the  tumor  in  every  case  diminish- 
ing. Segond 28  has  had  4  successes,  without  a  death ;  in  2  cases  with  im- 
mediate menopause  and  rapid  atrophy.  In  1  case  the  ojoeration  was 
unilateral,  the  menses  became  normal  and  painless,  and  the  tumor 
remained  stationary.  In  1  case  of  eight  months'  standing  there  was 
hamaatemesis.  Terrillon 2S  in  5  castrations  for  fibroma  had  one  death 
at  the  end  .of  two  months  from  continued  intestinal  compression.  It  is 
very  evident  that  in  this  case  the  castration  Avas  performed  as  a  make- 
shift, on  account  of  the  great  dangers  of  hysterectomy.  The  fatal 
termination  cannot  be  attributed  to  the  operation,  but  merely  shows 
how  powerless  is  castration  to  cause  rapid  diminution  of  large  tumors 
in  any  case.     In  4  other  cases  violent  hemorrhages  were  arrested. 

These  figures  show  both  the  relative  benignancy  of  the  operation 
and  its  value  when  judiciously  employed.  The  number  of  surgeons 
who  still  prefer  the  operation  of  hysterectomy  for  all  cases  is  becom- 
ing continually  smaller.30 


o26  CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 


BIBLIOGRAPHY. 

1.  SchrSder  and  Hofrueier:  Grand,  der  gyn.  Oper.,  p.  315. 

2.  Hegar  :  Centr.  f.  Gyn.,  No.  2,  1878;  No.  44,  1887  ;  Op.  Gyn.,  3d  ed.,  p.  341. 

3.  Battey:  Atlanta  Med.  and  Surg.  Jour.,  Sept.,  1872,  and  Amer.  Pract.,  1875. 

4.  Trenholme  :  Amer.  Jour.  Obst.,  1876,  p.  702.  His  operation  was  in  January, 
1876 ;  Hegar's  in  August  of  the  same  year.  Lawson  Tait,  Brit.  Med.  Jour.,  Aug. 
15th,  1885,  claims  that  he  performed  castration  for  uterine  fibroma  in  August,  1872; 
unfortunately  his  claim  is  made  too  late  for  it  to  be  taken  into  account. 

5.  Hegar:  Yolkmann's  klin.  Yort.  Gyn.,  Leipzig,  1878,  page  42.  Wiener  med. 
Woch.,  1878,  No.  15.  Centr.  f.  Gyn.,  1877,  No.  17,  and  1878,  No.  2,  and  1879,  No.  22. 
L>er  Zusammenhang  Geschlechtskrankh.  mit  nerv.  Leid.,  1885.  For  history — Hegar 
and  Kaltenbach  :  Die  oper.  Gyn.,  3d  ed.,  1886,  p.  341. 

6.  Wiedow :  Centr.  f.  Gyn.,  1882,  No.  6.     Arch.  f.  Gyn.,  Bd.  xxv.,  Heft  2. 

7.  Lawson  Tait :  British  Med.  Jour.,  1880,  No.  1,019,  p.  48.  Trans.  Obst.  Soc, 
London,  1883,  vol.  xxv.,  pp.  39  and  208. 

8.  Duplay:  Arch.  Gen.  de  MM.,  July,  1885. 

9.  Tissier  :  De  la  Castr.  de  la  Femme,  etc.     Paris  Thesis,  1885,  No.  208. 

10.  Segond  :  Annal.  de  Gyn.,  1888, "p.  416. 

11.  Hegar  and  Kaltenbach  :  Die  oper.  Gyn.,  3d  ed.,  p.  378. 

12.  Thornton :  Obst.  Soc,  London,  vol.  xxiv.,  p.  137. 

13.  On  the  contrary,  hysterectomy  seems  less  grave  when  done  for  fibro-cysts 
than  when  for  solid  tumors.     Gusserow  :  Loc.  cit.,  p.  295. 

14.  Winter :  Zeit.  f.  Geb.  und  Gyn.,  Bd.  xiv.,  Heft  2. 

15.  Lautier  :  Soc.  Anatomique,  May  11th,  1888.     See  remarks  of  Prof.  Cornil. 

16.  P.  Miiller  :  Beitrage  zur  operat.  Gynak.     Deutsche  Zeit.  f.  Chir.,  Bd.  xx. 

17.  Olshausen:  Centr.  f.  Gyn.,  January,  1888,  No.  10. 

18.  Hegar  and  Kaltenbach  :  Die  operat.  Gyn.,  3d  ed.,  1886,  p.  399. 

19.  Hofmeier  :  Zeit.  f.  Geb.  und  Gyn.,  Bd.  v.,  p.  106.  Geza  von  Antal :  Centr. 
f.  Gyn.,  1882,  No.  30.     Gustav  Crone  :  Inaug.  Dissert.,  Berlin,  August,  1883. 

20.  Segond:  Loc.  cit.,  p.  431. 

21.  Hegar  and  Kaltenbach  :  Loc.  cit.,  p.  405  et  seq. 

22.  Wiedow:  Loc.  cit. 

23.  Tissier,  loc.  cit.,  wrongly  attributes  this  case  of  Freund's  to  Hegar. 

24.  Lawson  Tait  :  British  Med.  Jour.  The  figure  1.23  is  evidently  an  error  of 
calculation,  for  it  is  often  repeated  in  his  publications. 

25.  Fehling  :  Wiirtemberg.  med.  Correspblatt.,  1887,  No.  3. 

26.  Prochownik :  Arch.  f.  Gyn.,  Bd.  xxix. 

27.  Bounty  :  Bull,  de  la  Soc.  Chir.,  June,  1888. 

28.  Segond  :  Ibidem,  and  in  Ann.  de  Gyn,,  1887,  p.  416. 

29.  Terrillon  :  Annales  de  Gyn.  et  d'Obst.,  p.  340,  1888. 

30.  Tillaux  and  Polillon  :  Bull,  de  la  Soc.  Chir.,  June,  1888. 


CHAPTER   XIII. 
FIBEOUS   TUMORS   COMPLICATING   PREGNANCY. 

A*  is  well  known,  pregnancy  gives  a  lively  impulse  to  the  devel- 
opment of  fibrous  tumors,  and  often  causes  their  cedematous  softening. 
This  phenomenon  is  the  more  marked  as  the  connections  of  the  tumor 
with  the  uterus  are  more  intimate,  and  attains  its  maximum  in  the 
case  of  interstitial  fibromata,  single  or  multiple,  with  great  increase 
in  the  uterine  wall,  as  in  those  cases  which  have  improperly  been 
described  as  hypertrophy  of  the  uterus.  This  sudden  augmentation 
in  the  size  of  the  tumor  exaggerates  any  symptoms  to  which  it  may 
have  given  rise,  the  pain  resulting  from  pressure  on  the  sacral  plexus 
becoming  at  times  intolerable.1  Retroflexion  of  a  gravid  uterus  with 
a  fibroma  causes  symptoms  of  internal  strangulation.2  When  the 
tumor  is  pelvic,  taking  its  origin  from  the  supra-vaginal  portion  of 
the  cervix,  and  developing  below  the  superior  strait,  the  compression 
signs  are  rapid  and  extreme;3  they  may  appear  in  connection  with 
the  bladder,  the  ureters,  the  rectum,  the  nerves  or  the  vessels,  and 
peritonitis  may  coexist.4  The  most  common  and  not  the  least  grave 
result  is  abortion;  and  as  involution  is  so  much  interfered  with, 
immediate  hemorrhage  and  septicaemia  are  both  very  likely  to  occur. 
Lef our 5  in  307  cases  found  39  abortions,  ending  fatally  to  the  mother 
14  times;  Naus  in  241  cases  observed  47  abortions.6 

The  treatment  depends  upon  the  nature  of  the  symptoms  caused 
and  the  seat  of  the  tumor.  If  it  is  a  pedicled  or  sessile  subserous 
fibroma  of  the  fundus  we  may  hope  that  it  will  not  interfere  with 
the  course  of  the  pregnancy.  If  there  is  danger  of  inflammation  or 
the  transformation  of  the  tumor  into  a  fibro-cyst,  there  is  also  a  hope 
that  it  will  disappear  during  the  uterine  involution  and  we  may 
therefore  pursue  the  expectant  treatment.  In  the  case  of  pelvic 
fibroids,  however,  delay  seems  more  dangerous ;  if  they  cause  no  very 
serious  symptoms  wre  may  wait  in  the  hojje  that  they  will  either  pre- 
cede the  fcetal  head  at  the  time  of  parturition,  as  has  been  observed, 
or  else  will  ascend  above  the  surjerior  strait  after  the  rupture  of  the 
membranes.     All  these  results  have  been  observed,  and  by  the  aid  of 


328  CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 

the  forceps  and  of  version  labor  has  been  successfully  terminated,  even 
in  desperate  conditions.7  In  such  a  case  one  should  attempt  to  re- 
duce the  tumor  by  pressing  it  back  with  the  hand  in  the  vagina.8 
Often  the  labor  is.  accomplished  only  after  a  duration  which  results  in 
a  fatal  exhaustion,  if  the  woman  does  not  die  at  once  of  the  hem- 
orrhage. These  risks  decidedly  limit  the  advisability  of  the  expectant 
method.  When  the  fibroma  is  accessible  its  extirpation  presents  less 
danger  than  waiting. 

Fibrous  tumors  of  the  cervix  are  of  this  class,  and  may  often  be 
enucleated  either  before  or  after  parturition.  Danyau 9  removed  one 
that  weighed  650  grams  and  measured  15  cm.  in  diameter.  Braxton 
Hicks 10  followed  enucleation  by  the  immediate  use  of  the  forceps 
and  ended  the  labor  without  difficulty.  J.  F.  Fry  "  reports  the  curious 
case  of  a  woman  who  had  been  delivered  of  nine  children  and  in 
whom  a  fibroma  of  the  anterior  lip  complicated  each  pregnancy.  At 
the  eighth,  a  portion  of  the  tumor  was  removed  with  the  ecraseur; 
on  the  ninth,  premature  labor  was  produced,  and,  immediately  after 
the  extraction  of  a  living  child,  almost  at  term,  the  fibroma,  whose 
base  measured  about  6  cm.  in  diameter,  was  enucleated. 

Munde 12  advocates  enucleation  by  the  vagina  in  any  case  where 
it  can  be  accomplished ;  in  16  cases  which  he  cites  the  mothers  died 
in  only  two,  and  the  children  were  for  the  most  part  living;  one  of 
these  was  his  own  personal  case. 

When  the  operation  is  performed  late  in  pregnancy,  there  may  be 
no  interruption  of  its  course ;  Mayo  Robson  13  removed  at  the  seventh 
month  a  fibroma  of  the  cervix  of  the  size  of  a  cocoa-nut.  The  opera- 
tion, performed  with  the  galvano-cautery,  was  followed  by  such 
copious  bleeding  that  many  ligatures  were  required,  but  there  were  no 
comrjlications  and  the  patient  went  on  to  a  normal  delivery  at  term. 

Polypi  may  be  expelled  before  the  foetal  head  when  their  pedicle 
has  been  torn;  of  this  Dubois  and  Dupaul  have  cited  cases.14  To 
facilitate  the  delivery  the  pedicle  may  be  cut.15  Fergusson's  error,  of 
placing  the  forceps  on  a  large  tumor,  thinking  that  it  was  the  foetal 
head,  should  not  be  committed ;  his  patient  died  from  rupture  of  the 
uterus.16  If  the  polyp  is  recognized  before  term,  it  may  be  extirpated 
without  interrupting  the  pregnancy;  Felsenreich 17  has  recently  pub- 
lished such  a  case  where  the  tumor  was  as  large  as  a  lemon. 

Interstitial  fibromata  with  an  abdominal  development  are  so 
nearly  inaccessible  that  any  operation  for  their  extraction  would  be 
too  grave,  and  we  ask  ourselves  whether  it  would  not  be  better  to 


FIBROUS   TUMORS   COMPLICATING-   PREGNANCY.  329 

produce  abortion.  The  feelings  of  the  surgeon  and  his  operative 
habits  enter  largely  into  the  solution  of  the  problem,  though  it  must 
not  be  forgotten  that  even  induced  abortion  is  not  free  from  dangers. 
If  the  placental  insertion  is  at  the  seat  of  the  tumor,  the  uterine  tissue 
may  not  be  able  to  contract  after  delivery,  and  thus  formidable  hem- 
orrhage can  occur.  The  patient  is  also  exposed  to  the  risk-  of  puer- 
peral septicaemia.     Lefour,  in  a  series  of  23  induced  abortions,  observed 

3  deaths.  Tarnier, 18  in  7  cases  where  the  labor  was  normal,  has  seen 
death  of  the  mother  once,  of  the  child  three  times.  In  6  cases  ter- 
minated by  the  forceps,  it  was  fatal  to  4  mothers  and  4  children.  In 
6  versions,  3  were  fatal  to  the  mother  and  3  to  the  child.  And  5 
women  who  had  fibromata  died  before  parturition ;  once  induced  abor- 
tion was  followed  by  success,  and  once  embryotomy  caused  the  death 
of  the  woman.  Siisserott,19  in  147  cases  of  pregnancy  complicated 
with  fibroma,  which  he  collected,  describes  20  where  the  forceps  were 
applied  with  death  of  the  woman  8  times  and  of  the  child  13;  in  20 
versions,  death  of  the  woman  12  times  and  of  the  child  17;  artificial 
extraction  of  the  placenta  21  times,  death  of  the  mother,  13  times :  in 
all  78  women  or  53^,  and  66#-  of  the  children  died. 

It  must  be  remembered  that  induced  labor  may  cause  the  expulsion 
of  a  non-viable  child,  that  it  does  not  relieve  the  compression  very 
much,  and  that,  if  we  have  to  perform  hysterectomy  afterward,  we 
have  exposed  the  life  of  the  patient  twice  instead  of  once :  these  are 
the  reasons  why  most  surgeons  prefer  early  interference.  Supra- 
vaginal amputation  is  evidently  better  than  the  Cesarean  operation, 
which  Cazin20  has  performed  with  success  in  the  seventh  month. 
This  author  has  collected  28  cases  of  Cesarean  section  which  were 
rendered  necessary  by  the  presence  of  a  fibroma  of  the  uterus ;  only 

4  of  the  women  were  saved,  15  children  were  born  alive,  8  were  ex- 
tracted dead ;  of  the  other  5  no  information  is  given.  Sanger 21  has 
recently  collected  43  cases  of  this  operation  for  fibroma,  in  which  7 
women  were  saved,  or  83.7$.     Tuffier22  has  published  one  fatal  case. 

When  it  is  decided  to  practise  hysterotomy,  if  the  fibroma  is  sit- 
uated in  the  middle  of  the  fundus  or  is  pedicled,  the  partial  operation 
of  myomectomy,  which  does  not  interfere  with  the  pregnancy,  should 
be  attempted.  AVhen  it  is  sessile  and  there  is  need  of  cutting  away 
the  uterine  tissue  in  the  neighborhood  of  the  tubes,  myomectomy  is 
attended  by  great  danger  of  hemorrhage,23  while  the  supra-vaginal 
operation  (Porro's)  is  rendered  easy  by  the  relaxation  of  the  liga- 
ments caused  by  the  pregnancy.24 


230 


CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 


Synopsis  of  Published  Results. 
I.— Simple  Myomectomy;  Uterus  Not  Removed. 


Author. 

Date  of  Operation  or 
Publication. 

Month  of  the 
Pregnancy. 

Anatomical  Condition. 

Result. 

Pean . .    .    

Hegar 

Clin.  Chir.,  Dec.  15, 

1874,  vol.  i.,  p.  679. 

Obst.  Trans.,  June 

4,  1879. 
Jan.,   1880;  Operat. 

Gynak.,  3d  edit., 

p.  475. 
Nov.  16,  1879,  cited 

bv  Hegar,  loc.  cit. 
Dec.  19,  1882,  cited 

by  Hegar,  loc.  cit. 

Ber.  Klin.Wochen., 

1885,  No.  3. 

Ber.  Klin.Wochen., 

1885,  No.  3. 

Fifth 

Seventh 

Third 

Fourth 

Three    and 
a  half. 

Sixth  . . 

Fibro-cystic  tumor. . . 

Tumor pedicled;  soft; 
peritonitis. 

Tumor  pedicled;  mul- 
tiple. 

Myomectomy,      with 
conoid    excision  of 
fundus  alone. 

Myoma,  on  right  side 
as  large  as  infant's 
head ;  on  left,  as  an 

Cure;  abor- 
tion   the 
day  after 
operation 

Death,  7th 
day. 

Death    3d 

Martin 

day. 

Cure;  nor- 
mal labor. 

Cure;  preg- 
nancy not 
disturbed. 

Death     7th 

day,    of 

hemor- 
rhage  af- 
ter  abor- 
tion. 

mal  labor. 

Can.  Pract.,  April, 
■    1885;  cited  by  Van 

der   Veer,   Amer. 

Journ.  Obst.,  1889, 

vol.  xxii.,  p.  1,138. 
Bull.  Soc.  Chirurg., 

Nov.,  1889. 
Hygeia,    1889,    Bd. 

li.,  No.  5,  p.  292. 

Not  given . . 

Third 
Fourth  ... 

egg. 
Interstitial     myoma, 
removed  by  enucle- 
a  t  i  o  n;  pregnancy 
not  diagnosed. 

Subserous    myoma 
with  large  base. 

Two   tumors,    the 
larger   size  of   two 
fists;  enucleation. 

Cure;  abor- 
tion     12 
days  later. 

Cure;     nor- 
mal labor. 

The  first  six  cases  are  from  Hegar  and  Kaltenbach;  I  have  added  the  others. 
II. — Supra- Vaginal  Amputation  op  Gravid  Uterus. 


Author. 

Date  of  Operation  or 
Publication. 

Month  of  the 
Pregnancy. 

Anatomical  Condition. 

Result. 

Kaltenbach 

Mar.  2,1880;  cited  by 
Hegar,  loc.  cit.,  p. 
475. 

March  18,  1880 

Feb.  10,  1882 

Jan.  10,  1883 

June  29,  1884 

Brit.    Med.   Assoc, 

Liverpool,  1883. 
St.  George's  Hosp. 

Rep.,  1874-6,  vol. 

viii.,  p.  91-5. 

Fifth 

Fifth 

Interstitial      myoma 

at  fundus;    weight 

3,500  gin. 
Interstitial      myoma 

of   fundus;    weight 

4,500  gm. 

Cure. 

Death,    6th 
day. 

Death  in  49 

Third 

Third 

Interstitial  myoma  of 
size  of  adult  head. 

hours. 
Cure. 

Cure. 

Fourth 

Third 

Fibroma    concealing 
pregnancy. 

Death,    9th 

day. 
Death. 

FIBROUS   TUMORS   COMPLICATING   PREGNANCY. 


331 


Author. 

Date  of  Operation  and 
Publication. 

Month  of  the 
Pregnancy. 

Anatomical  Condition. 

Result. 

Alex.  Patterson. 

Glasgow    Med. 
Jour.,  April,  1885. 

Fourth 

Fibroma     concealing 
pregnancy. 

Cure. 

Etheridge 

Am.    Jour.    Obst., 

Third  (use- 

Fibro-cystic tumor. . . 

Death,  on 

1887, vol.  xx.,  p.69. 

less    at- 
tempts to 
induce 
abortion 
had  been 
made). 
Fifth 

11th  day, 
of  perito- 
nitis. 

Hygeia,  April,  1887; 

Intra-  ligamentous; 

Cure 

analysis  in  Cent. 

pedicle  lost;  drain- 

f. Gyn.,  1887,  No. 
34. 
Unpublished     case 

age. 

Fibroma     concealing 

Cure. 

cited  by  Van  der 

pregnancy. 

Veer,  loc.  cit. 

G.  G.  Bantock . . 

Brit.    Gyn.     Jour., 
vol.  ii.,  p.  63. 

Third 

Fibroma     concealing 
pregnancv. 

Cure. 

Die     Myomotomie, 
p.  76. 

Third 

Fibroma;    pregnancy 
suspected. 

Cure. 

Cent.  f.  Gyn.,  1887, 
p.  119. 

Fibroma;  foetus  dead 
and  macerated. 

Cure. 

Cent.  f.  Gyn.,  1887, 
p.  435. 

Fibroma  disintegrat- 
ing;    foetus    mace- 
rated. 

Cure. 

D.  Van  Ott 

Arch.  f.  Gyn.,   Bd. 

Ninth;     263 

Large  fibroma  of  su- 

Cure; living 

xxvii.,  p.  88,  1890. 

days. 

pra-vaginal  portion 
of  cervix;  intra-peri- 
toneal  treatment  of 
pedicle. 
Tumor  of  lower  part 

child. 

Naturf.  Versaminl., 

Fourth    . . . 

Cure. 

Heidelberg,   1889; 

of  uterus. 

Cent.f.  Gyn.,  1890, 

p.  67. 

Most  of  these  cases  relate  to  operations  clone  before  the  ninth, 
month ;  if  Porro's  operation  is  attempted,  the  prognosis  is  very  grave, 
bnt,  as  an  important  consideration,  there  is  the  chance  of  saving  both 
mother  and  child.  This  operation  should  be  undertaken  a  few  days 
before  the  expected  time  of  parturition,  never  just  at  term,  for  fear  of 
being  surprised  by  labor.  The  operative  procedure  which  seems  to 
promise  the  greatest  immunity  from  hemorrhage  and  septicaemia, 
which  are  much  to  be  feared  when  the  uterus  is  gravid,  is  the  extra- 
peritoneal ligature  of  the  pedicle  (Hegar). 


BIBLIOGRAPHY. 

1.  Lefour:  Des  Fibrom.  Uter.  au  point  de  Vue,  etc.,  cites  four  cases  of  this 
kind  from  Tarnier  ;  Paris,  1880. 

2.  Lorimer  :  Edinburgh  Monthly  Journal,  July,  1866. 

3.  Depaul :  Union  HeU,  1857,  p.  548. 

4.  Worship:  Obstet.  Trans.,  London,  xiv.,  p.  305. 

5.  Lefour :  Loc.  cit. 


332  CLINICAL   AjSTD    OPERATIVE   GYNAECOLOGY. 

6.  Nauss  :  Inaug.  Dissert.,  Halle,  1882. 

7.  Felsenreich  has  cited  an  excellent  success  with  forceps:  Centr.  f.  Gyn.,  1889, 
p.  620. 

8.  Depaul,  Blot,  Gu^niot,  Tarnier  :  Bull,  de  la  Soc.  de  Chirurg.,  1874.  Porak  : 
Rep.  Univ.  d'Obst.,  etc.,  July,  1888,  p.  294. 

9.  Danyau  :   Bull.  Acad,  de  HeU,  1851. 

10.  B.  Hicks:  Obst.  Trans.,  vol.  xii.,  p.  273. 

11.  J.  F.  Fry:  Lancet,  1884. 

12.  Mund<§:  Amer.  Jour.  Obst.,  March,  1888,  p.  306. 

13.  Mayo  Robson  :  British  Med.  Jour.,  November  9th,  1889. 

14.  Deinarquay  and  Saint- Vel :  Malad.  de  l'Uterus. 

15.  J.  Bell :    Edinburgh  Med.  Jour.,  1820,  p.  365. 

16.  Ferguson,  cited  by  R.  Lambert:  Des  Gross.  Coinpliq.  de  Myom.  Uter. 
Paris  Thesis,  1870,  p.  119. 

17.  Felsenreich:  Wiener  med.  Woch.,  1887,   No.  52. 

18.  Tarnier :  Gaz.  des  H6pit.,  1869,  p.  175. 

19.  Stisserott :  Inaug.  Dissert.,  Rostock,  1870. 

20.  Cazin  :   Archiv.  de  Tocol.,  vol.  i.,  p.  704  and  vol.  iii.,  p.  321. 

21.  Sanger  :  Festschrift  zum  Jubilaum  Credo's,  Leipsic,  1881. 

22."  Tuffier  :  Ann.  de  Gynecol.,  November,  1889.  A  case  of  tumor  compressing 
the  ureter  and  causing  pyelo-nephritis;  discovered  at  the  autopsy. 

23.  Routier  :  Bull,  de  la  Soc.  de  Chirurg.,  November  15th,  1889.  Removal  of  a 
large  intra-ligamentous  fibroma  with  a  broad  base  and  suture  of  the  wound;  with- 
out accident. 

24.  See  entire  subject  treated  in  Vogel :  Ueber  supra-vag.  Amput.  desschwang. 
Uter.,  etc.  Inaug.  Dissert.  Giessen:  1887.  The  author  establishes  the  prior  rights 
of  Kaltenbach.  See  also  Meyer  (of  Zurich):  Die  Uterusfibr.  in  der  Schwang.  und 
der  Geb.,  etc.     Analysis  in  Centr.  f.  Gyn.,  1888,  p.  715. 


CHAPTER  XIV.. 

PATHOLOGY,   SYMPTOMS,   DIAGNOSIS,   AND   ETIOLOGY   OF 
CANCER   OF   THE   CEEVIX   UTERI. 

The  word  cancer  should  have  clinically  a  meaning  synonymous 
with  malignant  neoplasm.  A  malignant  character,  displayed  by  un- 
controllable invasion,  reproduction,  and  generalization,  is  encountered 
in  many  species  of  tumor  which  are  anatomically  distinct,  whose 
profound  study  interests  the  pathologist  more  than  the  surgeon,  but 
yet  furnishes  certain  indications  which  are  useful  in  the  matter  of 
prognosis. 

Pathological  Anatomy. — The  great  predisposition  of  the  cervix  to 
the  development  of  cancer  has  been  noticed  by  all  observers.  Is  there 
anything  in  general  anatomy  which  will  explain  the  fact?  Cohnheim 
has  supposed  that  the  embryonal  cells  (embryoplastic  cells  of  Ch. 
Robin)  which  have  not  been  absorbed  in  the  formation  of  the  organs, 
and  which  are  found  scattered  through  the  connective  tissue  or  gath- 
ered in  islands  at  certain  points,  may  be  the  matrix  tissue  of  carci- 
noma. These  tumors  are  found  most  frequently  in  the  nests  of  em- 
bryonal cells  which  define  the  natural  orifices,  where  there  is  a  more 
or  less  irregular  involution  of  the  blastodermic  layers;  the  cervix 
uteri,  developed  relatively  late,  at  the  expense  of  the  Mullerian  ducts, 
belongs  in  this  class  of  congenitally  vulnerable  points.  The  presence 
of  two  varieties  of  epithelium  at  the  external  os  and  the  consequent 
plastic  polymorphism  which  results  may  also  be  a  factor  in  their  pro- 
duction. There  remains  unexplained,  however,  the  exciting  cause  of 
the  neoplasm;  the  repeated  afflux  of  blood  upon  which  Cohnheim 
lays  so  much  stress  does  not  account  for  it. 

In  epithelioma  of  the  mucous  membrane  it  is  evident  that  the 
heterologous  formation  proceeds  from  the  epithelial  cells,  either  of 
the  rete  Malpighii  (Klebs),  or  from  the  cylindrical  cells  within  the 
cervix  which  have  passed  the  external  os  (Schroder),  or  from  the 
glandular  cells  (Ruge  and  Veit).  In  cancer  of  the  uterine  paren- 
chyma, the  histogenic  origin  of  the  cells  of  the  neoplasm  is  very  ob- 
scure.    Virchow  derives  them  solely  from  the  connective-tissue  cells, 


334 


CLINICAL   AXD    OPERATIVE   GYNAECOLOGY. 


which  accords  with  Cohnheim's  hypothesis,  and  the  latest  researches 
of  Huge  and  Yeit  go  to  support  the'  idea.  According  to  these  ob- 
servers, cancer  is  usually  a  transformation  of  these  connective-tissue 
cells,  sometimes  into  a  papillary  or  cauliflower  form.  The  connective 
tissue  becomes  vascular  and  returns  to  the  embryonic  condition,  and 
the  cells  take  on  an  epithelial  character ;  exceptionally  an  adenoma, 
also  the  product  of  these  epithelial  elements,  may  become  cancerous. 

Anatomical  Forms. — From  the  clinical  point  of  view,  when  these 
tumors  are  seen  at  the  start,  and  before  they  have  altered  the  primi- 
tive aspect  of  the  parts  by  their  spread  to  adjacent  structures,  we  can 
distinguish  four  classes— (1)  the  papillary,  (2)  the  nodular,  (3)  of  "the 
cervical  cavity,  and  (4)  the  vaginal. 


Tig.  167 


-Papillary  Cancer  of  the  Cervix:  Pavement  Epithelioma  of  the  External  Os.    Section, 

natural  size. 


1.  Papillary  Form  (Syn.:  Superficial  cancer  of  the  cervix,  vege- 
tating or  cauliflower  cancer). — This  form  begins  on  that  part  of  the 
cervix  which  is  below  the  vaginal  insertion,  and  may  remain  for  a  long 
time  limited  to  it.  Often  it  starts  from  cylindrical  epithelium  which' 
has  invaded  the  external  surface,  as  we  have  seen  in  the  case  of 
metritis;  this,  without  ulceration,  though  at  first  benign,  is  trans- 
formed into  an  epithelioma.  It  may  take  on  a  fungous  appearance, 
the  os  and  the  healthy  lip  being  hidden  beneath  it,  and  for  a  long 
time  show  no  tendency  to  spread;  but  there  comes  a  time  when  it 
attacks  the  cul-de-sac,  involves  it  both  superficially  and  deeply,  and 
passes  on  to  the  peri-uterine  tissues ;  or  the  extension  may  take  place 
along  the  cervical  canal. 

There  is  always  an  accompanying  lesion  of  the  mucous  membrane 
of  the  body  of  the  organ:1  Abel  in  seven  cases  from  Landau's  clinic 


PATHOLOGY  OF  CANCER  OF  THE  CERVIX  UTERI. 


335 


found  in  three  a  sarcomatous  degeneration,  and  in  two  others  an 
interstitial  endometritis  which  appeared  to  be  developing  toward 
sarcoma.  He  states  that  the  malignant  degeneration  is  produced  con- 
comitantly, though  under  a  different  histological  form,  in  the  two 
regions.  These  assertions  of  Abel  are  strongly  disputed  and  far  from 
being  established.2 

2.  Nodular  Form  (Syn. :  Parenchymatous  cancer,  cancerous  no- 
dosities, circumscribed  or  infiltrated  cancer).— This  form  starts  as  one 
or  several  nodules  in  the  mucous  membrane  of  the  cervix,  on  either 
the  external  or  the  internal  surface,  with  ulcerations  only  late  in  the 
disease.  By  its  progress  it  destroys  the  mucosa,  and  thus  a  cancerous 
ulceration  results.     Then  nodules  in  the  cervix  and  body  fuse  with 


Fig.  168.— Cancer  of  the  Cervix,  Nodular  Form. 
p,  Zone  of  intact  pavement  epithelium ;  /,  cancerous 
nodule;  a,  external  os;  c,  cervix. 


Fig.  169. 


-Beginning  Cancer  of  the  Cervix, 
Ulcerative  Form. 


the  first,  and  soon  the  whole  organ  and  the  adjacent  tissues  are  in- 
volved. 

3.  Cancer  of  the  Cavity  (Syn. :  Cancer  of  the  cervical  mucous  mem- 
brane, boring  or  eating  cancer).— This  form  develops  at  first  in  the 
cervical  mucous  membrane,  or  just  below  it,  by  an  infiltration  which 
soon  ulcerates  and  causes  a  slow  destruction  of  the  part  by  erosion; 
there  are  cases  of  this  kind  where  the  cervix  becomes  a  mere  shell, 
and,  with  the  retraction  which  is  noticed  as  in  the  case  of  cancer  of 
the  breast,  it  may  nearly  disappear.  The  body  of  the  uterus  is  early 
involved,  then  the  peri-uterine  connective  tissue,  and  the  vagina  last 
or  not  at  all. 

4.  Vaginal  Form. — This  is  far  more  unusual  than  the  others,  be- 
gins in  the  posterior  cul-de-sac  as  certain  cancers  of  the  tongue  start 
from  the  floor  of  the  mouth,  and  invades  equally  the  cervix  and  the 
adjacent  portions  df  the  vagina,  producing  extensive  ulcerations. 


336 


CLINICAL   AND    OPERATIVE    GYNAECOLOGY, 


Histological  Varieties. — The  three  kinds  which  are  most  often 
found  are:  (1)  Pavement  epithelioma;  (2)  cylindrical  epithelioma;  (3) 
carcinoma  or  atypical  epithelioma.  In  France,  since  the  writings  of 
Ch.  Robin,  Cornil,  and  Malassez,  the  epithelial  origin  of  cancer  is  the 
most  favored  doctrine,  and  carcinoma  is  considered  as  an  alveolar  epi- 
thelioma, a  particular  kind,  an  evolutionary  stage  "of  epithelioma, 
and  not  as  a  neoplasm  developed  from  the  first  at  the  expense  of  the 
connective-tissue  cells.1 

Pavement  epithelioma,  lobulated  or  tubulated,  is  seldom  general, 
though  Virchow  has  observed  it.  The  cylindrical  form  has  the  most 
frequent  metastasis. 


Fig.  170.— Cylindrical  Epithelioma  prom  the  Upper  Part  of  the  Cervis,  Invading  the  Fundus 
(x  150.)  m,  3,  Hypertrophied  glands  of  the  body  of  the  uterus,  like  those  of  chronic  metritis;  t,  enlarged 
glandular  cavity,  the  walls  showing  many  layers  of  epithelium;  e,  adjacent  gland  wall,  in  a  similar  state; 
v,  vessels;  c,  connective  tissue  (Cornil). 

Pavement  epithelioma  is  often  found  in  the  superficial  forms, 
papillary  and  vaginal ;  the  variety  called  lobulated  is  formed  by  cel- 
lular masses  which  separate  the  still  evident. muscular  bundles,  and 
which  may  undergo  either  a  mucous  or  corneous  change.  Tubu- 
lated cancers  are  formed  of  cylinders  stuffed  full  of  epithelial  cells 
which  anastomose  and  penetrate  between  the  muscular  trabecule 
that  still  resist  the  invasion,  and  on  section  we  see  in  the  lumen  of 
such  tubes  pavement  cells  becoming  cubical  and  others  deformed  by 
pressure. 

Cylindrical  epithelioma  is  usually  the  form  which  begins  in  the 
cervix  and  spreads  along  its  cavity,  and  resembles  that  of  the  uterine 
body  (Figs.  170,  171,  172).  It  begins  by  a  typical  glandular  prolife- 
ration (adenoma)  and  ends  as  an  atypical  (malignant  adenoma),  which 


PATHOLOGY  OF  CANCER  OF  THE  CERVIX  UTERI. 


337 


is  simply  an  epithelioma.  Cornil  insists  on  the  great  histological 
resemblance  between  glandular  endometritis  and  certain  develop- 
mental stages  of  cylindrical  epithelioma. 


Ti  ■fe-tsJ*>j_r< 


4  KARMANSKI- 

Fig.  171.— Cylindrical  Epithelioma  of  the  Body,  Extended  from  the  Cervix  (X  150).  c,  c,  Connec- 
tive tissue;  a,  cavity  full  of  cells,  the  external  layer  being  cylindrical.  These  cells  have  a  tendency  to 
become  detached  from  the  wall,  well  seen  at  o  ;  /,  cavity  with  mucous  cells,  and  large  cells  in  mucous 
degeneration  (Cornil). 


The  atypical  epithelioma,  or  carcinoma  of  most  German  authors, 
is  not  clearly  distinguished  from  certain  forms  of  tubulated  pave- 


Fig.  172. — Cylindrical  Epithelioma  of  the  Body,  Extended  from  the  Cervtx  (X  400).    b,  Single 
layer  of  epithelium;  fc,  cells  showing  karyokinesis;  n,  free  degenerating  ceil;  d,  adjacent  alveolus  (Cornil). 

ment  epithelioma ?  it  is  characterized  by  polymorphism  of  its  cells, 
which  correspond  to  those  of  the  alveolar  wall  or  to  those  of  the 
gland,  and  by  their  disposition  in  masses  within  the  alveoli,  whose 


338 


CLINICAL   AND    OPEEATIVE   GYNAECOLOGY. 


walls  are  formed  by  anastomosing  bands  of  connective  tissue  (Fig. 
173).  When  the  fibrons  stroma  is  small  in  amount  and  the  cells  are 
swollen  and  predominant,  the  tumor  is  called  encephaloid  (Fig.  176); 
when  they  are  hard  and  dry,  it  is  called  scirrhus  (Fig.  168). 


Fig.  173.— Carcinoma,  or  Atypical  Epithelioma.  Section  of  one  of  the  nodules  of  Fig.  168.  On  the 
median  edge  of  the  section  the  pavement  epithelium  ceases  and  is  replaced  by  an  erosion  presenting 
a  structure  almost  papillary  and  more  or  less  ramified  glands.  The  stroma  is  formed  of  fibrous  bands 
which  divide  the  aveoli  of  different  sizes  and  these  again  are  subdivided  by  smaller  bands.  The  aveoli 
are  filled  with  polymorphic  cell  elements;  the  exact  origin  of  the  cell-nests  is  difficult  to  determine;  they 
are  apparently  from  glandular  cavities,  of  which  some  are  covered  with  a  single  layer  of  cylindrical 
epithelium.  These  cavities  are  transformed  to  solid  cords  by  the  proliferation  of  the  cells;  the  normal 
glands  can  be  followed  from  the  surface  up  to  the  middle  of  the  cancerous  nodule  (Wyder). 


Extension. — At  an  advanced  period  of  the  disease  the  charac- 
teristics peculiar  to  each  form  are  lost  in  the  destruction  and  grave 
symptoms  caused  by  its  extension,  either  to  the  vagina,  the  body,  the 
connective  tissue  of  the  pelvis  and  the  broad  ligaments,  the  ureters 
and  bladder,  the  rectum,  or  the  peritoneum. 

Extension  to  the  vagina  may  be  found  at  the  outset,  may  occur  rap- 
idly in  the  papillary  form,  and  may  reach  the  vulva  (Fig.  174). 

Invasion  of  the  body  occurs  late  in  the  papillary  form,  but  it 
should  not  be  forgotten  that  the  mucous  membrane  of  the  part  may 
also  undergo  a  degeneration  of  an  intensely  inflammatory  nature  by 
which  it  is  made  very  liable  to  invasion  (Abel).  The  body  of  the 
organ  is  very  soon  involved  in  the  case  of  tumor  of  the  cervical  cav- 
ity, and  in  the  nodular  form  may  be  infected  from  the  first. 

The  pelvic  connective  tissue  may  be  invaded  from  the  cul-de-sac, 
the  cervix,  or  the  fundus  ;  the  uterus  is  then  imprisoned,  as  if 


PATHOLOGY    OF    CAXCER    OF   THE    CEEVTX    UTEIII. 


339 


glue  had  been  poured  about  it  and  had  hardened.  The  broad  liga- 
ments become  thick  and  shortened,  and  toward  the  end  the  ves- 
sels and  nerves  of  the  lower  pelvis,  especially  the  branches  of  the 
sacral  plexus,  may  be  involved,  when  Ave  observe  oedema  and  intense 
pain. 

The  ureters  are  often  involved,  for  instead  of  merely  pushing  them 
out  of  the  way,  as  does  a  fibroma,  the  neoplasm  assimilates  them  little 
by  little;  occasionally  the  wall  of  these  ducts  may  be  ulcerated 
through,  and  thus  a  fistula  pro- 
duced. Most  frequently  the  ureter 
is  constricted ;  its  calibre  being  di- 
minished at  the  lower  end,  the 
duct  is  dilated  up  to  the  pelvis  of 
the  kidney  by  the  constant  accum- 
ulation of  urine  under  high  pres- 


Fig.  17-1. — Epithelioma  of  the  Cervix  Extending 
to  the  Vagina  ;  Papillary  Form. 


Fig.  175. — Epithelioma  of  the  Cavity  of  the 
Cervix.  On  the  left  is  an  extension  toward  the 
fundus  of  the  uterus. 


sure.  The  great  frequence  of  renal  disease  in  cancer  of  the  uterus  has 
been  known  for  a  long  time,  and  recently  made  the  subject  of  special 
study.  Lancereaux 3  asserts  that  this  ascending  nephritis  is  con- 
stant when  the  disease  is  at  all  advanced,  and  during  twenty-five 
years  I  have  never  seen  it  absent  at  autopsy,  unless  the  patient  had 
died  prematurely  from  metrorrhagia. 

The  experiments  of  Straus  and  Clermont i  on  the  effects  of  ligation 
of  the  ureters  in  animals,  which  confirm  and  explain  the  older  observa- 
tions of  Aufrecht  in  Germany  and  Charcot  and  Gombault  in  France, 
clearly  explain  these  lesions.     They  found  that  ligation  produced  a 


340 


CLINICAL   AND   OPEEATIVE   GYNECOLOGY. 


progressive  atrophy  of  the  kidney  which  destroyed  the  distinction  of 
cortical  and  medullary  portions,  and  that  the  papillae  and  pyramids 
disappeared.  These  lesions  closely  resemble  those  found  at  the  au- 
topsy of  women  dead  of  cervical  cancer.5  The  ureters  are  dilated  to 
the  size  of  the  external  iliac  artery,  or  even  to  that  of  the  small  intes- 
tine, their  walls  are  thickened  and  at  times  tortuous;  the  pelvis  of 
the  kidney  is  distended,  especially  at  the  lower  part,  and  of  a  conical 
or  pyriform  shape.     When  its  dimensions  are  very  large,  it  forms  a 


Fig.  176.— Encephaloid  Epithelioma  of  the  Cervix  Invading  the  Body  op  the  Uterus. 


tumor  which,  according  to   Eayer's  comparison,  is  covered  by  the 
remaining  portions  of  the  kidney  as  with  a  helmet. 

The  characteristic  lesion  is  in  the  modifications  of  the  pyra- 
mids and  papillae;  the  papillae  become  flattened  and  their  apices 
depressed,  so  that  where  there  was  a  projection  a  hollow  is  formed. 
Later  there  is  no  trace  of  secreting  tissue  left,  but  in  its  place  a 
fibrous  membrane  limiting  a  cavity  crossed  by  the  columns  of  Ber- 
tini,  which  persist  for  some  time,  so  that  the  kidney  has  a  multi- 
lobed  and  cystic  aspect. 


PATHOLOGY   OF   CANCER   OF   THE   CERVIX   UTERL 


341 


The  cellular  tissue  which  unites  bladder  and  cervix  may  be  in- 
vaded, then  the  bladder.  Soon  after  there  is  a  catarrhal  inflamma- 
tion produced;  small  sections  of  the  bladder  wall  may  slough  or  be 
eaten  through  by  the  morbid  tissue,  which  penetrates  the  vesical  cav- 
ity and  establishes  a  fistula  (Fig.  177). 

Ureteritis  and  septic  pyelo-neiAritis  are  some  of  the  first  and 
gravest  consequences  of  the  bladder  invasion ;  its  result  may  be  mili- 
ary abscess  of  the  kidney,  but  this  is  less  common  than  interstitial 
nephritis.  In  their  statistics,  which  cover  51  cases,  Caron  and  Fere 6 
found  suppurative  pyelitis  and  miliary  abscess  7  times ;  in  all  the 


Fig.  177.— Cancer  of  the  Cervix  which  has  Extended  to  tht:  Vagina  and  Perforated  the  Bladder. 


others  there  were  only  mechanical  lesions,  such  as  dilatation  of  the 
ureters,  hydro-nephrosis  and  nephritis.  Lancereaux,  in  23  cases,  has 
not  described  suppuration  of  the  kidney  even  once. 

We  would  expect  that  the  heart  would  be  influenced  by  this  kid- 
ney lesion,,  and  in  certain  cases  there  is  found  hypertrophy  of  the  left 
ventricle,  as  Traube's  theory  requires.  This  theory  is  that  the  kid- 
ney lesion  destroys  a  certain  number  of  arterioles  and  lessens  the  .cir- 
culatory domain,  augmenting  thus  the  inter-arterial  pressure ;  to  this 
is  added  the  functional  insufficiency  of  the  kidney,  which  causes  the 
retention  in  the  blood  of  an  abnormal  amount  of  water  besides  the 
excrementitious  matters ;  the  cardiac  hypertrophy  is  the  direct  neces- 


342  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

sary  consequence  of  these  two  factors.  In  a  work  intended  to  sup- 
port this  theory,  Straus 7  cites  2  cases  of  cervical  cancer  with  second- 
ary nephritis  and  great  hypertrophy  of  the  heart;  4  similar  cases  are 
published  by  Artaud,8  and  still  others  by  Weill  and  Thouvenet 9  in 
their  theses.  But  in  1884  Lancereaux  published  a  memoir  based  on 
23  cases  of  his  own  observation,  in  which  he  reaches  the  opposite 
conclusion.  In  these  23  autopsies  the  heart  was  weighed  and  all  its 
details  carefully  examined,  and  in  21  it  was  either  normal  or  small 
and  atrophied.  Often  it  was  soft  and  covered  with  fat  on  its  anterior 
and  basal  surfaces.  In  only  2  cases  was  there  any  increase  in  weight 
and  volume,  and  then  there  was  also  an  arterial  lesion  (aortic  endar- 
teritis, or  insufficiency)  to  explain  the  hypertrophy.  This  important 
series  seems  to  be  demonstrative.  It  is  thus  probable  that  the  cardiac 
lesion  accompanies  the  nephritis  of  cancer  only  exceptionally,  in 
cases  where  the  latter  is  of  very  rapid  development.10  There  is  still 
another  lesion  of  the  heart  which  is  at  times  found  at  the  autopsy  of 
cancer  of  the  uterus  which  Lancereaux  calls  "  verrucous  "  endocarditis, 
and  which  he  found  twice  among  his  23  cases.  Under  this  name  he 
describes  a  special  vegetating  form  of  endocarditis  which  differs  en- 
tirely from  the  ordinary  inflammation  which  is  present  in  cases  of 
cachectic  disease  like  tuberculosis ;  but  the  exact  nature  of  the  vege- 
tations is  not  decided ;  probably  they  are  of  microbic  origin. 

The  rectum  is  seldom  involved  and  fistula  of  it  is  rare. 

The  peritoneum  resists  the  ingrowth  of  the  neoplasm  by  the  pro- 
duction of  adhesions  which  limit  the  disease  to  a  small  focus ;  thus 
it  occurs  that  the  recto-vaginal  pouch  appears  to  be  so  far  from  the 
vaginal  cul-de-sac  when  we  perform  hysterectomy. 

In  very  advanced  cases  we  find  the  vagina  transformed  into  a 
cloaca,  opening  both  into  the  bladder  and  into  the  rectum;  above, 
the  lower  pelvis  is  filled  with  a  cancerous  mass  in  which  the  fundus 
and  adnexa  can  be  recognized  only  with  difficulty,  being  covered  by 
adherent  coils  of  intestine,  which  may  also  be  jDerforated. 

Lastly,  there  may  be  metastasis  to  distant  organs,  as  the  liver, 
kidney,  stomach,  and  lungs. 

The  iliac,  prevertebral,  and  inguinal  ganglia  are  often  involved. 
The  inguinal  ganglia,  contrary  to  the  general  opinion,  may  be  in- 
volved without  disease  of  the  vagina.  The  lymphatics  of  the  cervix 
communicate  with  those  of  the  body,  and  these  again  with  the  in- 
guinal ganglia  through  the  lymph  vessels  which  accompany  the  round 
ligaments.     This  was  described  first  by  Mascagni  and  rediscovered  by 


SYMPTOMS    OF   CANCER   OF   THE   CERVIX   UTERI.  343 

i 

Poirier.11  Troisier  lias  recently  called  attention  to  the  adenopathy  of 
the  left  subclavicular  region  which  is  at  times  produced,  independently 
of  the  invasion  of  the  lung  and  the  pervertebral  ganglia,  in  general  or 
abdominal  cancer,  but  especially  in  uterine.13  It  is  probable,  as  Troi- 
sier supposes,  that  this  isolated  manifestation  is  due  to  direct  infec- 
tion of  the  ganglia  by  reflux  of  the  lymph  from  the  thoracic  duct 
where  the  ganglia  empty  into  it  by  short  trunks.  This  curious  ana- 
tomical fact  is  at  the  same  time  a  valuable  contra-indication  to  opera- 
tion. 

Among  the  deuteropathic  and  distant  lesions  may  be  noted  fatty 
degeneration  of  the  liver  as  described  by  Leca.13  It  appears  that  the 
septic  material  absorbed  by  the  organism  from  the  ulcerating  surfaces 
acts  like  a  steatogenic  poison  on  the  liver,  as  do  alcohol  and  phos- 
phorus. This  fatty  degeneration  of  the  liver  was  long  ago  described 
among  other  surgical  septicaemias  by  Yerneuil. 

Symptoms. — The  onset  of  the  disease  is  insicjious,  and  there  may 
be  a  long  period  during  which  it  is  latent  and  the  patient  preserves 
every  appearance  of  health  with  a  lesion  already  far  advanced ;  for 
this  reason  it  is  unusual  to  observe  the  initial  symptoms.  The  atten- 
tion is  first  attracted  by  a  small  loss  of  blood  at  some  other  time  than 
the  regular  period,  after  some  exertion,  especially  coitus.  But  this 
accident,  often  happening  in  women  who  are  approaching  the  meno- 
pause, is  taken  for  an  unimportant  irregularity  and  passes  unnoticed 
until  by  its  repetition  it  becomes  alarming.  At  other  times  these 
hemorrhages  occur  with  some  regularity  every  month  and  are  viewed 
with  satisfaction  as  a  return  of  menstruation  and  the  index  of  re- 
newed youth. 

The  early  bleeding  does  not  come  from  an  ulcerated  surface,  but  is 
due  to  the  complicating  metritis,  or  simply  to  the  congestion  caused 
by  the  presence  of  the  tumor ;  the  process  may  be  compared  to  the 
haemoptysis  of  the  first  months  of  pulmonary  tuberculosis. 

At  the  same  time  leucorrhcea  without  any  special  characters  ap- 
pears; then  the  pain,  the  reflex  phenomena  from  the  digestive  tract, 
the  circulation  and  the  nervous  system,  produce  the  pathological 
cycle  which  I  have  described  in  the  chapter  on  metritis  as  the  uterine 
svndroma.  But  the  diagnosis  must  not  be  made  without  a  local  ex- 
animation,  in  which  the  touch  recognizes  the  induration,  or  papillary 
and  ulcerated  condition,  of  the  cervix,  and  the  speculum  demonstrates 
the  livid  aspect  of  the  tumor,  the  yellowish  surface  of  the  ulcerations, 
and  the  cauliflower  or  fungous  vegetations. 


344  CLINICAL  AND   OPERATIVE   GYNAECOLOGY. 

Soon  after  follows  the  second  stage,  which  may  be  called  the  period 
of  acme,  when  all  the  symptoms  are  present;  the  hemorrhage  be- 
comes more  frequent,  there  is  a  reddish  discharge  with  a  stale  odor, 
or  fetid  and  disgusting,  and  so  copious  and  acrid  that  it  causes  ery- 
thema of  the  thighs  and  pruritus  vulvae,  which  are  very  distressing. 
At  the  same  time  the  pain,  chiefly  lumbar,  is  very  severe,  and  with  it 
there  are  neuralgic  radiations  in  different  directions.  By  touch  the 
vaginal  pouches  may  be  found  free,  but  they  are  often  already  in- 
vaded, the  uterus  remaining  movable  or  becoming  more  or  less  fixed 
by  extension  of  the  morbid  process  to  the  pelvic  cellular  tissue. 
The  results  of  the  local  examination  by  touch  are  far  more  trust- 
worthy than  by  the  speculum;  it  is  surprising,  if  the  usual  order  is 
reversed,  to  see  how  the  finger  discovers  alterations  incomparably 
more  extensive  than  those  which  can  be  seen.  A  cervix  which  seems 
to  be  a  little  swollen  and  ulcerated  by  the  speculum  is  felt  by  the 
finger  as  a  large  tumor  deeply  changed  by  an  already  advanced 
process. 

The  digestive  symptoms,  anorexia,  constipation,  meteorism,  etc., 
have  by,  this  time  become  of  great  importance  and  interfere  with  the 
general  nutrition.  With  this  condition  begins  the  third  stage,  or  the 
cancerous  cachexia;  the  skin  having  a  pale  yellow  tint  which  Barnes 
attributed  to  the  absorption  of  fecal  matters  retained  by  the  obsti- 
nate constipation  (cojDrsemia).  The  skin  is  also  peculiarly  harsh  and 
dry.  At  this  time  also  there  may  be  present  painful  cystitis,  intoler- 
able neuralgia  from  compression  or  invasion  of  the  nerves,  phlegmasia 
alba  dolens,  and  fistulas ;  local  examination  revealing  wide  extension 
of  the  neoplasm  to  the  adjacent  parts.  There  may  coexist  with  all 
this  successive  attacks  of  subacute  uraemia,  and  on  analysis  of  the 
urine  the  excretion  of  urea  is  found  to  be  subnormal,  due  not  so  much 
to  the  general  enfeeblement  as  to  insufficiency  of  the  renal  filter;  the 
sign  of  these  attacks  is  an  exaggeration  of  the  stomach  disorder  with 
vomiting. 

The  uraemia  gradually  becomes  chronic  and  constitutes  an  actual 
source  of  comfort  to  the  patient,  as  it  blunts  both  intelligence  and 
sensibility.  After  a  few  days  in  this  condition,  indifferent  to  all  sur- 
roundings, semi-comatose  and  hardly  responding  to  questions,  the 
patient  quietly  dies;  this  is  the  usual  history,  convulsions  of  an 
eclamptic  form  being  rare.  I  have  seen  one  case  of  uraemia  with 
dyspnoea.  Peritonitis  by  extension  or  perforation,  or  embolism  may 
cause  a  speedily  fatal  termination.     It  is  evident  that  septicaemia  may 


DIAGNOSIS    OF   CANCER   OF   THE   CERVIX   UTERI.  345 

enter  largely  into  the  production  of  the  later  effects;  and  if  there  is 
no  jjroper  treatment  of  it,  this  alone  may  be  the  cause  of  death. 

Complicating  Pregnancy. — Conception  may  occur  with  cancer  of 
the  cervix,  as  is  proved  by  many  cases,14  although  the  conditions  are 
very  unfavorable  to  fecundation.  It  often  happens  that  women  re- 
turn to  their  physician  with  a  new  pregnancy  in  whom  a  cancer  had 
complicated  the  x3revious  one.  Cancer  predisposes  to  abortion.  In  one 
hundred  and  twenty  women  with  cancer  of  the  cervix  treated  during 
pregnancy  by  Lewer  at  Guy's  Hospital,  forty  per  cent  aborted.15 
Hanks16  thinks  that  the  abortion  occurs  most  often  in  the  third 
month,  and  that,  if  the  patient  passes  this  period  in  safety,  the 
chances  are  that  labor  will  take  place  at  full  term. 

Chantreuil 17  cites  three  cases  of  prolonged  pregnancy,  the  most 
interesting  being  a  case  of  Menzies'  of  Glasgow.  At  times  there  is  a 
series  of  ineffectual  efforts  at  expulsion  occurring  at  intervals  and 
exhausting  the  patient,  and  in  one  of  these  the  uterus  may  be  rup- 
tured.18 

The  prognosis  for  a  woman  with  cancer  is  always  aggravated  by 
pregnancy,  for  abortion  may  cause  a  fatal  hemorrhage  or  septicaemia, 
arid  when  the  case  goes  on  to  full  term  the  labor  is  dangerous ;  Her- 
man 19  found  forty  cases  of  death  in  labor  in  one  hundred  and  thirty- 
seven  cases  of  this  kind.  The  older  statistics  show  an  even  higher 
mortality,  Chantreuil  giving  25  deaths  for  60  labors,  and  West  41  in  75. 
Among  one  hundred  and  twenty-eight  children  of  cancerous  mothers 
only  a  few  were  born  alive. 

Diagnosis. — I  have  already  given  the  differential  diagnosis  be- 
tween cancer  before  the  ulcerative  period  and  chronic  metritis,  and 
between  cancer  after  ulceration  and  catarrhal  metritis  of  the  cervix 
(p.  343).  Stratz  lays  much  stress  upon  the  yellow  color  and  the  bril- 
liant granular  aspect  of  non-ulcerated  cancer.20  In  all  doubtful  cases 
a  section  should  be  cut  and  examined  microscopically.  If  we  are 
forced  to  wait,  the  course  of  the  disease  will  remove  the  doubt;  almost 
always  where  the  nature  of  the  disease  is  uncertain,  it  is  not  cancer. 

The  benign  vegetations  observed  in  vaginitis  with  mucous  patches 
and  papilloma  could  not  be  confounded  with  cancer;  their  multipli- 
city, their  dissemination,  and  the  characteristic  cock's-comb  aspect 
will  prevent  error,  while  the  purulent  excretion  of  vaginitis  is  very 
different  from  the  reddish,  fetid  discharge  characteristic  of  cancer. 

A  circumscribed,  cancerous  nodule  in  the  cervix  may  be  difficult 
to  distinguish  from  a  small  myoma,  though  the  latter  is  more  clearly 


346  CLINICAL   AND   OPEEATIVE   G-YISTJECOLOGrY. 

defined  and  there  is  no  sign  of  infiltration  or  inflammation  abont  it; 
the  mucous  membrane  is  not  adherent  to  the  fibrons  tumor,  as  it  is  to 
the  cancerous.21 

Certain  cylindrical  epitheliomata  of  the  cervix  present  a  polypoid 
appearance  which  might  be  confounded  with  benign  mucous  polypi ; 23 
in  such  cases  the  cancerous  nodules  of  the  uterine  body  and  neck 
begin  to  project  toward  the  exterior.  A  decision  may  be  reached  by 
dilatation  and  intra-uterine  touch,  or,  if  necessary,  by  exploratory 
curetting.   * 

All  these  considerations  apply  to  cancer  at  the  very  first;  later. on 
in  the  course  of  the  disease,  the  invasion  of  adjacent  parts,  the  prog- 
ress of  the  ulceration,  the  frequent  hemorrhage,  and  the  abundant 
fetid  discharge  render  the  diagnosis  easy.  There  is,  however,  an  affec- 
tion with  which  it  may  be  confounded,  namely,  sloughing  fibroma  of  the 
cervix,  or  polyp  of  the  body  arrested  by  strangulation  or  adhesions  at 
the  external  os,  which  is  dilated  and  partially  effaced  when  the  fibroma 
has  been  altered  by  spontaneous  decomposition  or  by  the  application 
of  caustics.  Hemorrhage,  fetid  discharge,  and  a  fungous  or  sphace- 
lated appearance  of  the  neoplasm  all  concur  in  making  the  case  un- 
certain; the  patient,  exhausted  by  profound  ansemia,  seems  to  present 
the  cancerous  cachexia.  There  is  but  one  symptom  which  removes 
the  doubt,  but  it  is  pathognomonic:  we  should  always  seek  for  the 
external  os,  and  in  the  case  of  a  fibroma  it  will  be  found  as  a  thin  con- 
tinuous collar  about  the  tumor,  and  the  tip  of  the  finger  may  be  in- 
troduced between  the  morbid  mass  and  this  diaphragm;  frequently, 
also,  the  tumor  is  firm  and  free  from  ulceration  along  its  margin.  In 
one  case  of  this  kind  I  operated  successfully  and  enucleated  a  spha- 
celated intra-cervical  fibroma  in  a  patient  who  had  been  sent  away  by 
a  distinguished  physician  as  afflicted  with  incurable  cancer. 

The  following  are  exceptional  forms  of  malignant  disease  of 
the  cervix:  Hegar23  found  a  very  rare  form  in  an  old  woman,  the 
hypertrophied  cervix  projecting  beyond  the  vulva,  with  no  ulceration. 
Eckhardt24  observed  in  a  young  woman  of  nineteen  years  a  con- 
siderable hypertrophy  of  the  cervix  which  seemed  to  immediately 
precede  its  cancerous  degeneration.  Schroder  found  on  autopsy  a 
cancer  of  the  upper  part  of  the  cervix,  intra-cervical,  of  which  there 
was  nothing  to  be  discovered  externally.25  Sarcoma  of  the  cervix  has 
been  exceptionally  observed,  but  so  rarely  that  it  cannot  be  consid- 
ered a  clinical  entity;  its  variable  manifestations  might  render  diag- 
nosis difficult. 


DIAGNOSIS    OF    CANCER   OF   THE    CERVIX    UTERI. 


347 


Spiegelberg 26  described  in  1878  a  curious  case  which  lie  called 
sarcoma  colli  hydropicum  papillare  (dropsical  papillary  sarcoma  of 
the  cervix)  in  a  young  woman  of  seventeen  years.  There  was  a 
papillary  tumor  of  the  anterior  lip  which  returned  six  months  after 
ablation  and  filled  the  whole  vagina,  like  a  hydatid  chorionic  mole; 
the  microscope  demonstrated  that  it.  was  a  sarcoma  with  cedematous 
infiltration  of  its  stroma.     The  same  author  observed  a  similar  case 


Fig.  178.— Myxo-Sarcoma  of  the  Cervix  (Pernice). 
L,  Line  of  excision ;  a,  b,  lobules  of  the  tumor;  c,  shreds 
of  an  enveloping  membrane. 


Fig.  179.— Fibro-Adenoma  of  the  Cervix 
(Thomas). 


in  a  woman  thirty-one  years  old  in  1878;  and  Winckler2t  cites  a  case 
of  Sanger's  which  resembles  it. 

Ludwig  Pernice 2S  has  given  a  description  of  a  strio-cellular  myo- 
sarcoma of  the  uterus,  in  the  form  of  a  bunch  of  grapes,  in  a  nullipara 
who  had  suffered  from  hemorrhage  for  six  months.  The  tumor  started 
from  the  external  os  and  was  of  the  volume  of  about  10  cm.  in  all 
diameters,  with  lobules  of  a  violet  color  filled  with  a  gelatinous  fluid; 
it  was  removed  by  the  bistoury.  On  examination  it  proved  to  be  a 
sarcoma  mixed  with  striated  muscular  fibres  of  an  embryonic  appear- 
ance. Two  months  afterward  it  returned  and  was  removed  again,  this 
time  being  nearly  half  as  large  as  at  first;  and  in  nine  months  more 
the  patient  returned  with  a  tumor  which  reached  almost  to  the  epigas- 
trium.    Exploratory  laparatomy  was  performed  and  death  followed 


348  CLINICAL  AND   OPEEATIVE   GYNAECOLOGY. 

from  pneumonia;  the  microscope  showing  that  both  the  second  and 
the  third  tumor  were  sarcomatous,  but  without  any  sign  of  myxoma- 
tous degeneration. 

Munde29  has  described  a  tumor  which  was  evidently  malignant  and 
which  he  considered  a  myxo-adenoma  transformed  into  a  myxo- 
sarcoma, in  a  patient  of  nineteen  years  who  had  suffered  from  intense 
leucorrhoea  and  complete  amenorrhcea  for  two  years.  The  vagina  was 
filled  and  the  hymen  protruded  by  a  friable  tumor  composed  of  lobules 
of  the  size  of  a  muscatel  grape ;  on  removal  by  the  snare  its  centre  was 
found  to  be  fibrous,  and  it  proved  to  have  started  from  the  cervix,  in 
places  showing  a  myxomatous  degeneration  of  the  vaginal  culs-de- 
sac.  One  month  and  a  half  later  it  returned.  Histologically  it  was 
composed  of  a  multitude  of  myxomatous  cysts,  in  whose  fibrous  stroma 
there  were  many  lymph  corpuscles  and  sarcomatous  cells.  It  seemed 
to  Munde  that  it  was  a  case  of  malignant  degeneration  of  a  tumor 
which  was  at  first  benign. 

Thiede 30  has  described  under  the  name  of  fibroma  papillare  car- 
tilaginescens  a  tumor  observed  in  a  woman  of  forty  years,  lobulated 
and  spongy  in  apjDearance,  taking  origin  from  the  mucous  membrane 
of  the  cervix.  Its  ablation  was  followed  by  recurrence  and  death. 
On  section  there  were  found  islands  of  hyaline  cartilage  in  a  stroma 
rich  in  dilated  vessels,  but  none  of  the  characters  of  a  sarcoma.  To 
this  may  be  compared  Rein's  case 31  of  what  he  calls  an  arborescent 
enchondromatous  myxoma  of  the  cervix,  found  in  a  patient  of 
twenty-one  years,  the  tumor  being  lobulated  and  soft.  It  was  removed 
entire,  but  rapidly  returned,  and  caused  death.  On  section  the  soft 
tissue  was  found  to  be  subdivided  by  bands  of  fibrous  structure 
surrounding  masses  of  aspect  and  structure  like  Wharton's  jelly,  and 
in  the  middle  of  these  myxomatous  portions  there  were  nodules  of 
hyaline  cartilage. 

Lastly,  Winckel 32  describes  a  myxomatous  adenoma  of  the  cervix 
which  he  removed  from  the  anterior  lip  of  the  uterus  of  a  woman 
forty  years  old,  with  rapid  recurrence  and  invasion  of  the  vaginal 
pouches,  when  the  patient  passed  out  of  his  observation.  On  section 
the  tumor  was  full  of  alveoli  containing  mucus,  and  the  microscope 
proved  that  it  had  probably  been  at  first  an  adenoma  which  then  be- 
came transformed  into  a  sarcoma  and  then  underwent  myxomatous 
degeneration.  This  singular  hybrid  neoplasm  established,  according 
to  this  author,  a  transition  between  epithelioma  and  sarcoma. 

All  of  these  rare  cases  deserve  mention,  but  their  differences  in- 


PROGNOSIS   AND   ETIOLOGY   OF   CANCER   OF  THE   CERVIX.        349 

terest  the  pathologist  more  than  the  clinician ;  they  are  all  malignant 
tumors  and  may  be  called  cancer. 

An  important  part  of  the  diagnosis  is  the  determination  of  the 
tumor's  extension.  Bimanual  palpation,  with  systematic  infra-trac- 
tion of  the  uterus,  will  furnish  the  needed  information  on  this  point, 
and,  if  necessary,  anaesthesia  may  be  employed  to  facilitate  the  exam- 
ination, which  is  so  important  from  the  operative  point  of  view. 

Prognosis. — Cancer  in  all  its  forms  runs  a  fatal  course,  but  some 
forms  develop  more  slowly  than  others ;  for  example,  scirrhus  cancer 
of  the  cavity. 

The  average  duration  of  the  disease  is  from  sixteen  or  seventeen 
months,  according  to  Courty,  to  twelve  months  (Gusserow);  but 
Simpson  says  two  or  two  and  a  half  years,  and  Fordyce  Barker  up  to 
three  years  and  eight  months.  Arnott,  who  has  published  scanty 
but  well-studied  statistics,  assigns  to  carcinoma  (of  the  cavity?)  a 
duration  of  fifty -three  to  fifty-four  weeks,  and  to  epithelioma  (pap- 
pillary)  eighty -two  to  eighty -three  weeks;  cases  of  longer  duration 
have  been  cited.  Courty 33  speaks  of  a  woman  who  lived  seven  to 
eight  years,  Fordyce  Barker 34  of  one  who  lived  eleven  years,  after  the 
first  signs  were  discovered,  and  Emmet 35  asserts  that  he  has  seen  life 
prolonged  from  five  to  eight  years;  these  cases  may  be  compared  to 
certain  forms  of  atrophic  scirrhus  of  the  breast. 

The  age  of  the  patient  is  of  great  importance.  Generally,  cancer 
at  the  age  of  twenty  or  thirty  develops  more  rapidly  than  at  the  time 
of  the  menopause ;  with  tumors  of  a  galloping  course,  where  there  is 
rapid  return  even  after  hysterectomy  performed  under  the  most  fa- 
vorable conditions,  the  patient  is  generally  young. 

The  form  of  the  tumor  should  also  be  considered  in  the  prognosis. 
It  may  take  years  to  develop  those  of  the  cavity  and  the  hard  variety 
with  but  little  bleeding  or  vegetation,  especially  if  the  patient  is  of 
advanced  age. 

Etiology. — Women  are  more  subject  to  cancer  than  men,  and  it  is 
the  uterus  which  is  most  frequently  attacked.  This  fact  has  been 
proved  beyond  doubt  by  J.  Y.  Simpson's  statistics  in  the  "  Annual 
Report  of  the  Registrar-General  for  England"  of  the  years  1847-61. 

During  the  period  which  may  be  called  the  uterine  life  of  the 
woman  this  frequency  is  most  manifest ;  that  is,  from  puberty  to  the 
menopause  when  it  attains  its  maximum.  After  the  uterus,  the  breast 
is  most  often  attacked. 

Race,  heredity,  age,  and  environment   are  general  predisposing 


350 


CLINICAL   AND    OPERATIVE   GYNECOLOGY. 


causes:  the  influence  of  race  in  the  United  States,  where  it  can  be 
well  studied,  is  to  the  benefit  of  the  negress,  in  whom  cancer  of  the 
uterus  is  so  rare  while  fibroma  is  so  common.  According  to  Chis- 
holm's  statistics,  nearly  one  in  every  one  hundred  whites  die  of  can- 
cer and  only  one  in  three  hundred  blacks,  both  sexes  included. 

The  force  of  heredity  has  been  disputed.  In  collecting  the  statis- 
tics which  he  first  published,  Schroder  found  in  nine  hundred  and 
forty-eight  cases  that  this  factor  could  be  determined  in  only  seventy- 
eight.     I  have  seen  many  incontestable  cases. 

The  period  at  which  it  most  frequently  develops  is  between  the 
ages  of  forty  to  fifty  years.  Examples  are  known  of  very  early  devel- 
opment of  cancer  of  the  cervix.  Ganghcffer  records  the  case  of  a  child 
of  nine  who  for  two  years  had  had  losses  of  blood  together  with  an 
ulcerating  tumor  which  filled  the  vagina.  The  child  died  of  variola 
a  few  days  after  its  excision  and  cauterization.  Microscopic  exami- 
nation by  Chiari  proved  it  to  be  a  medullary  carcinoma,  probably 
from  the  glands.  The  principal  statistics  are  combined  in  the  follow- 
ing table  by  Gusserow,37  who  has  added  to  his  own  results  those  of 
Lever,  Kiwisch,  Chiari,  Scanzoni,  Saxinger,  Tanner,  Hough,  Blau,  Dit- 
trich,  L.  Meyer,  Lebert,  Glatter,  Beigel,  Schroder,  Schatz,  Winckel, 
and  Champneys;  in  all  3,385  cases: 

Age  at  which  Cancerous  Disease  Began. 
17  years,    ... 


19 

20  to  30 

30 

"  40 

40 

"  50 

50 

"  60 

60 

"  70 

1 

"  (Beigel) 

114  cases 

770 

u 

.   1,196 

u 

856 

u 

340 

u 

193 

u 

above 70     " 

Unsanitary  environment,  with  privations  leading  to  poor  nutrition, 
favor  the  development  of  cancer,  so  that  it  is  most  often  observed  in 
the  lower  classes  of  society ;  the  opposite  is  true  of  myoma. 

Schroder  has  drawn  up  comparative  statistics  of  the  cases  he  has 
seen  in  hospital  and  private  practice,  which  are  of  great  interest- 
Myoma. 


Cancer. 


In  14,000  hospital  cases,      .        .     385  (1.9#) 
"  16,800        "  "  . 

"     9,400  of  private  practice,       .     537  (5.70) 


603  (3.6#) 
209  (2.10) 


ETIOLOGY  OF  CANCEE  OF  THE  CERVIX  UTERI.         351 

Martin  has  made  a  similar  list,  and  finds  that  three  per  cent  of  his 
hospital  cases  were  cancerous,  and  a  slightly  large  proportion  myo- 
matous; in  his  private  practice  the.results  were  like  Schroder's. 

Local  predisposing  causes  which  have  been  mentioned  are,  lacera- 
tion and  metritis  of  the  cervix  (Emmet  and  Breisky);  Mangin33 
has  made  histological  researches  on  the  point  of  great  interest.  He 
also  instances  the  effect  of  repeated  parturition,  but  it  is  possible 
that  this  repetition  acts  only  by  the  lacerations  and  inflammations 
which  are  its  consequence. 


BIBLIOGRAPHY. 

1.  K.  Abel :  Arch.  f.  Gyn.,  Bd.  xxxii.,  Heft  2,  1888.  Abel  and  Landau:  Ibid., 
Bd.  xxxv.,  Heft  2,  1889. 

2.  E.  Frankel  :  Ibid.,  Bd.  xxxiii.,  Heft  1,  1888. 

3.  Lancereaux  :  Annales  des  Mai.  des  Org.  Genit.-urin.,  1884. 

4.  Straus  and  Gercnont :  Archiv.  de  Physiol.,  1882. 

5.  L.  Leca :  Des  Lesions  Second,  du  Cancer  de  TUt^r.     Paris  Thesis,  1888. 

6.  Fere"  and  Caron  :   Progres  Med.,  1883,  p.  1,049. 

7.  Straus  :  Archiv.  Gen.  de  MeU,  1882. 

8.  Artaud  :  Revue  de  M£decine,  November,  1883. 

9.  "Weil:  Hypert.  Card,  dans  les  2s"eph.,  etc.  Lyons  Thesis,  1882.  Thou  vent : 
Paris  Thesis,  1888. 

10.  Letulle :  Progres  Medical,  1886,  p.  737. 

11.  Barraud :   Paris  Thesis,  1889,  pp.  19,  20. 

12.  Troisier :  L1  Adenopath.  sus-clav.  Gauche,  etc.  Report  on  a  case  of  Andre 
Petit:  Bull,  de  Mem.  de  la  Soc.  Me"d.  des  H6pit.,  January  13th,  1888,  and  Archiv. 
Gen.  de  Med.,  February-March,  1889. 

13.  Leca  :   Loc.  cit.,  p.  55  (5). 

14  La  very:  Obst.  Trans.,  London,  vol.  xx.,  p.  82. 

15.  Lewer,  cited  by  Gallard  :   Lee.  sur  les  Malad.  des  Femmes,  p.  961. 

16.  Hanks:  Amer.  Jour.  Obst.,  March,  1888,  p.  252. 

IT.  G.  Chantreuil :  Influence  du  Cancer  de  TUter.  sur  la  Concep.,  etc.,  Paris, 
1872.     Bar:  Du  Cancer  Uter.  pend.  la  Gross.,  etc.     Paris  Thesis,  1886. 

18.  Bousquet :  Repert.  Univ.  d*Obst.  et  de  Gynec.,  1889,  p.  387.  Extraction  at 
term  of  a  macerated  child  by  version. 

19.  Herman:  Obst.  Trans.,  London,  vol.  xx.,  p.  206. 

20.  Stratz  :  Zeits.  f.  Geb.  und  Gyn.,  Bd.  xiii.,  Heft  1. 

21.  Spiegelberg :   Arch.  f.  Gyn.,  Bd.   hi.,  1872. 

22.  Montfumat  :  Paris  Thesis,  1867.  A.  Richet  :  Gaz.  des  Hopit.,  August  25th, 
1885. 

23.  Hegar :   Virchow's  Archiv,  1872,  Bd.  lv.,  p.  245. 

24.  Eckhardt:   Centr.  f.  Gyn.,  1887,  No.  37. 

25.  Schroder  :   Mai.  des  Org.  G£n.  de  la  Fem.,  Fr.  ed.,  p.  312. 

26.  Spiegelberg:   Arch.  f.  Gyn.,  xiv.,  p.  178,  and  xv.,  p.  437. 

27.  Winckler:    Arch.  f.  Gyn.,  xxi.,  p.  309. 

28.  Pernice  :  Virchow's  Archiv,  July  3d,  1888. 

29.  Munde1  :  A  rare  case  of  adeno-myxo-sarcoma,  etc.  Amer.  Jour.  Obstetrics, 
February,  1889,  p.  126.     G.  Thomas :   Diseases  of  Women,  1880,  p.  560.     O.  Weber  : 


352  CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 

Ueber  die  Bildung  quergestreifter  Muskelfasern.     Virchow's  Arch.,  Bd.  xxxix.,  p. 
216. 

30.  Thiede:  Zeit.  f.  Geb.  und  Gyn.,  1877,  Bd.  i.,  p.  460. 

31.  Rein:  Arch.  f.  Gyn.,  Bd.  xv.,  p.  187,  1870. 

32.  Winckel:   Lehrbuch  der  Frauenkr.,  1886,  p.  430. 

33.  Courty:   Traite"  Pratique  des  Mai.  de  l'Ut.,  3d  ed.,  p.  1,160. 

34.  F.  Barker:   Am.  Jour.  Obst.,  Nov.,  1870. 

35.  Emmet:   Prin.  and  Pract.  of  Gyn.,  p.  513. 

36.  Ganghoffer:   Prag.  Zeits.  f.  Heilk,  Bd.  ix.,  Heft  4  and  5.     See  also  Spiegel- 
berg's  and  Eckhardt's  cases. 

37.  Gusserow:  Die  Neubildungen  des  Uterus,  Stuttgart,  1885. 

38.  Mangin:  Marseille  MeU,  Sept.,  1888. 


CHAPTER  XV. 

TREATMENT   OF   CANCER   OF    THE   CERVIX. 

The  treatment  of  cancer  may  be  divided  into  two  sections  accord- 
ing as  it  is  palliative  or  radical;  the  latter  is  possible  only  when  the 
tumor  is  limited  to  the  uterus  itself  without  invasion  of  other  parts. 
Palliative  treatment  is  addressed  to  cancers  which  have  passed  be- 
yond the  limits  of  the  organ  where  complete  ablation  would  be  either 
impossible,  too  dangerous,  or  useless. 

I.  Cancer  of  the  External  Os  Not  Involving  the  Vaginal 

Culs-de-sac. 

Until  recently  no  attempt  was  made  toward  a  radical  cure  of 
uterine  cancer  unless  the  neoplasm  was  limited  to  the  vaginal  portion 
of  the  cervix,  and  in  such  cases  intra- vaginal  amputation  was  per- 
formed. The  operation  has  given  good  results  in  the  hands  of 
Verneuil,  who  uses  the  ecraseur,  C.  Braun,  who  employs  the 
galvano-caustic  loop,  and  Schroder,1  who  advises  a  cutting  instrument, 
which  I  consider  both  quicker  and  safer.  Very  brilliant  results 
have  been  credited  to  both  these  methods,  but  in  many  of  the  older 
cases  there  is  an  uncertainty  of  diagnosis.  Pawlik's 2  statistics  from 
Braun's  clinic  cover  about  twenty  years:  In  136  intra-vaginal  ampu- 
tations of  the  cervix  by  the  galvano-caustic  loop,  9  died  from  the 
operation  (6.6$);  33  cases  were  followed  more  than  one  year  (24$);  26 
more  than  two  years  (19$);  2  were  still  exempt  at  the  end  of  twelve 
years,  1  at  the  end  of  nineteen  and  one-half.  Verneuil  in  October, 
1888,  reported  22  operations  by  his  method,  with  1  death.  Polaillon, 
who  used  the  galvano-caustic  loop,  had  1  death  (from  chloroform)  in 
200  cases.  Marchand,  in  12  cases,  4  by  the  ecraseur  and  8  by  the  gal- 
vanic loop,  had  1  death  from  opening  the  peritoneum  and  peritonitis. 
Terrillon  had  7  cures.  Adding  one  case  of  Schwartz's  we  obtain  60 
amputations  of  the  cervix,  with  2  deaths  from  operation  (3.33$). 
Among  these  Verneuil  has  1  case  of  cure  of  seven  years'  standing,  1  of 
five  years,  and  1  of  three  years ;  2  of  six  years  and  three  years,  re- 
spectively, presented  a  return  of  the  disease  in  the  pelvic  ganglia. 

23 


354 


CLENTCAL   A15TD    OPERATIVE   GYNAECOLOGY. 


Polaillon  gives  1  case  of  cure  after  seven  and  1  case  after  five  years; 
Marchand,  1  case  after  seven  and  1  after  five  years;  Schwartz  1  after 
four  years.3 

I  consider  the  employment  of  the  bistoury  superior  to  all  other 
methods  of  excision,  for  it  permits  an  operation  which  is  thoroughout 
intelligent  and  not  mechanical,  and  by  it  the  ablation  may  be  carried 
as  far  upward  as  may  be  necessary.  I  therefore  Use  the  cutting  in- 
strument according  to  the  rules  already  given  under  the  treatment  of 
metritis  (pp.  207,  208).  As  I  have  said  before,  when  the  lesion  is  can- 
cerous, no  matter  how  small,  I  perform  total  hysterectomy;4  yet  the 
great  authority  of  my  illustrious  master  Professor  Verneuil  will  not 
permit  me  to  omit  the  description  of  the  operative  details  of  amputa- 
tion of  the  cervix  by  the  ecraseur.5  The  greatest  care  must  be  exer- 
cised, in  applying  the  instrument,  to  avoid  all  upward  displacement  of 
the  chain,  for  it  has  happened  that  by  this  accident  the  recto-vaginal 
pouch  has  been  opened  with  a  fatal  result. 


YerneuiVs  Method  of  Intro-vaginal  Amputation  of  the  Cervix. 

First  Step — Perforation  of  the  Cervix. — The  patient  is  placed  in 
the  lithotomy  position,  the  fourchette  depressed  by  a  Sims  speculum, 
and  the  cervix  drawn  down  by  a  Museux  forceps.  A  trocar  is  passed 
in  upon  the  finger  introduced  into  the  posterior  vaginal  pouch  and  the 
uterus  pierced  perpendicularly  to  its  axis,  the  index  finger  being  placed 
in  the  anterior  pouch  to  determine  the  point  where  it  shall  pass  out, 
the  Sims  blade  being  removed  for  the  purpose,  and  the  cervix  drawn 
down  by  an  assistant.  When  the  cervix  has  been  pierced  through, 
the  stylet  is  withdrawn  and  replaced  by  a  small  urethral  bougie,  which 
is  seized  with  forceps  and  drawn  to  the  vulva;  the  canula  of  the 
trocar  is  then  removed.  By  means  of  the  bougie,  two  strong  ligatures, 
about  fifty  centimetres  in  length,  are  then  passed  through  the  cervix 
and  the  ends  brought  out  of  the  vulva.  One  of  these  loops  serves  to 
pass  the  first  chain  and  the  other  to  fix  and  draw  down  the  cervix; 
the  hooks  or  forceps  are  no  longer  of  use  and  may  be  removed.  In 
the  absence  of  a  curved  trocar,  a  long  and  strong  channelled  sound 
may  be  employed  (Broca),  such  as  is  used  in  linear  rectotomy.  After 
giving  it  a  convenient  curve,  about  like  that  of  a  Cooper's  needle,  it 
may  be  well  sharpened  for  its  passage  through  the  uterine  tissue, 
and  a  sharp  stylet  guided  along  its  channel  to  carry  the  ligatures 
as  described  above. 


I 


TREATMENT  OF  CANCER  OF  THE  CEETIX.  355 

Second  Step — Introduction  of  the  Chains. — The  only  precautions 
needed  in  this  step  will  be,  care  to  turn  the  concave  side  of  the  chain 
toward  the  cervix,  in  tightening  it  to  pass  well  beyond  the  limits  of 
the  disease,  and  to  apply  it  as  perpendicularly  as  possible  to  the  axis 
of  the  part.  For  the  latter  purpose,  an  assistant  may  draw  down  the 
uterus  with  the  other  ligature,  turning  it  toward  the  side  opposite  the 
chain,  while  the  rigid  handle  of  the  ecraseur  is  carried  upward  and 
the  constricting  loop  is  held  on  the  nail  of  the  index  finger  until  it 
has  traced  its  furrow  in  the  cervical  tissue. 

Third  Step — Section  of  the  Cervix. — If  we  wish  to  have  the  oper- 
ation really  bloodless,  it  must  be  performed  very  slowly.  When  the 
chain  is  tight  enough  to  feel  the  resistance  of  the  tissues,  it  is  increased 
by  one  notch  every  thirty  seconds ;  and  when  a  peculiar  sound  an- 
nounces that  the  tissues  have  yielded  to  the  pressure,  the  interval  is 
lengthened  by  ten  seconds.  It  is  important  to  keep  this  up  till  the 
very  last  notch,  or  there  will  be  hemorrhage  during  the  final  minutes 
of  the  operation.  Two  ecraseurs  may  be  employed,  the  second  being 
passed  as  the  first,  and  thus  the  operation  much  shortened.  "With 
but  one  we  proceed  as  follows:  Before  the  section  is  entirely  com- 
pleted, the  second  ligature  is  used  to  tie  the  other  half  of  the  cervix 
perpendicularly  to  its  axis;  then,  when  it  is  finished,  the  chain  is 
placed  in  the  furrow  of  this  ligature  and  the  section  completed. 

Dressing  and  After -treatment. — The  section  accomplished,  the 
part  excised  should  be  examined  with  great  care  to  see  that  all  the  dis- 
eased tissue  has  been  removed  and  that  the  peritoneum  has  not  been 
included;  if  not,  then  a  gentle  injection  of  a  carbolic  solution  (1  :  50) 
is  kept  up  till  the  fluid  returns  clear  or  but  little  tinged  with  blood. 

If,  however,  there  is  a  wound  of  the  peritoneum,  it  must  be  closed 
with  a  few  points  of  suture,  although  nature  alone  will  sometimes 
occlude  it.  If  the  examination  of  the  wound  shows  that  certain  por- 
tions of  diseased  tissue  remain,  Lisfranc's  or  a  boxwood  speculum 
may  be  introduced  and  the  last  vestiges  of  the  neoplasm  destroyed 
with  the  thermo-cautery  or  the  sharp  curette. 

The  dressing  is  very  simple.  Yerneuil  places  in  front  of  the  vulva 
a  compress  of  iodoformed  or  carbolized  gauze. 

For  my  part,  I  think  that  total  hysterectomy  is  preferable  to  re- 
moval of  the  cervix,  even  when  the  disease  is  circumscribed,  for  it 
alone  gives  security  that  the  whole  of  the  affected  part  has  been  re- 
moved, and  the  mortality  of  the  operation  has  been  so  far  reduced  that 
it  does  not  materially  exceed  that  of  cervical  amputation. 


356 


CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 


II.  Cancer  of  the  Entire  Cervix,  without  Extension  to 

THE   CULS-DE-SAC. 

In  this  condition  intra-vaginal  amputation  will  not  suffice,  for  it 
does  not  include  the  whole  of  the  disease.  We  therefore  practise  the 
supra-vaginal  excision,  a  conical  excision  similar  to  that  which  Huguier 
long  since  applied  to  another  affection  and  which  many  surgeons 
independently  of  each  other  have  practised  under  different  names. 
Kceberle6  has  "for  nearly  twenty  years"  performed  a  conical  ex- 
cision with  the  bistoury,  using  a  sound  in  the  cervix  as  a  guide, 
and  "  roasting  "  the  stump  with  the  thermo-cautery.     Baker,  of  Bos- 


Fig.  180.— Supra- Vaginal  Amputation  of  the  Cervix,  showing  the  Extent  of  the  Excision  and  the 
Ligature  of  the  Lower  Branch  of  the  Uterine  Artery. 

ton,7  also  employs  the  "  high  amputation,"  followed  by  the  hot  iron, 
and  Ely  van  de  Warker 8  does  the  same,  cauterizing  with  chloride  of 
zinc. 

Schroder  has  made  the  operation  general,  and  best  described  the 
indications  and  technique  under  the  name  of  supra-vaginal  amputa- 
tion of  the  cervix.9  According  to  him  there  is  a  fundamental  differ- 
ence between  cancroid  (epithelioma)  of  the  cervix  and  all  other  forms 
of  cancer.  He  believes  it  to  be  a  local  affection,  with  no  tendency 
toward  propagation  to  the  body  of  the  organ  if  the  cervix  is  freely 
excised,  the  limits  of  the  disease  being  passed  by  from  one  to  one 
and  a  half  centimetres. 

The   technique  is  as   follows:    The   diseased  cervix   is  brought 


TREATMENT  OF  CANCER  OF  THE  CERVIX.  35 1 

down  to  the  vulva  by  Museux  forceps  and  a  strong  loop  of 
thread  is  passed  through  and  above  each  of  the  lateral  culs-de-sac 
(Fig.  180).  These  loops  serve  to  draw  the  parts  down,  and  to  com- 
press the  uterine  artery. 

A  transverse  incision  is  then  made  across  the  anterior  cervico-vaginal 
junction,  at  least  one  centimetre  from  the  diseased  part,  extending 
into  the  connective  tissue.  The  bladder  is  then  easily  separated  over 
a  large  extent  by  tearing  the  loose  connective  tissue  between  it  and  the 
cervix.  The  forceps  are  then  elevated  so  that  the  posterior  cul-de-sac 
is  exposed,  and  a  transverse  incision  made  through  the  vagina  as  be- 
fore, with  usually  some  difficulty  in  separating  the  peritoneum  from 
the  posterior  vaginal  wall.  If  from  the  extent  of  the  disease  we  are 
obliged  to  make  this  latter  incision  high  up  on  the  vaginal  wall,  the 
peritoneum  is  likely  to  be  opened,  and  if  this  is  avoided,  there  is  still 
the  danger  of  wounding  it  in  several  points  during  the  separation  of 
the  vaginal  tissues.  The  serous  membrane  is  easily  recognized,  even 
when  not  wounded,  from  its  bluish  and  transparent  appearance;  but 
opening  it  is  a  matter  of  indifference  when  the  operation  is  antiseptic, 
and  it  is  only  necessary  to  close  it  with  a  few  sutures  and  cut  the 
ends  short.  When  the  vagina  is  thus  divided  in  front  and  behind, 
the  incisions  are  prolonged  laterally  till  they  meet,  and  the  separated 
cervix  detached  from  its  connections  by  the  finger.  It  is  difficult  to 
do  this  on  the  sides,  for  there  the  connective  tissue  is  dense  and  the 
vessels  enter  the  uterus.  Before  the  latter  are  cut  they  should  be  tied, 
a  second  ligature  being  applied  if  necessary.  Then  when  the  cervix  is 
free  enough,  its  anterior  wall  is  incised  with  the  bistoury  as  far  as  the 
canal,  and  sutures  are  passed  through  the  anterior  cul-de-sac  and  along 
the  posterior  wall  of  the  bladder,  traversing  the  uterine  wall  and 
coming  out  in  the  cervical  canal  (Fig.  181).  These  are  then  tied,  em- 
bracing the  parts  deeply  and  closing  the  wound  in  the  connective 
tissue  so  that  the  cut  surface  of  the  anterior  vaginal  wall  is  ap- 
plied to  the  cut  surface  of  the  cervical  mucous  membrane.  Then 
the  posterior  lip  of  the  cervix  is  divided,  the  sutures  preventing  the 
stump  from  escaping  upward,  and  sutured  in  the  same  manner.  The 
union  of  the  parts  is  then  completed  by  lateral  sutures,  and  the 
entire  bleeding  surface  closed  by  ligatures  placed  as  deeply  as 
possible. 

This  operation  permits  the  complete  removal  of  most  of  the  vaginal 
cul-de-sac,  the  entire  cervix  and  a  .part  of  the  uterine  body ;  Schroder 
has  also  excised  at  the  same  time  the  upper  portion  of  the  vagina. 


358 


CLINICAL  AND   OPEBATIYE   GYNAECOLOGY. 


Hofmeier10  has  published  the  results  of  Schroder  and  some  of 
his  assistants  from  the  beginning  of  1879  to  the  end  of  1884;  in  105 
partial  extirpations  there  MTere  but  10  deaths,  or  9.5$,  and  the  final 
results  were  excellent.  In  Germany  this  operation  has  been  per- 
formed by  Gusserow;  u  in  America  by  Baker  and  Reamy; 12  in  Eng- 
land by  Spencer  Wells  and  Wallace ; 13  and  in  France  by  Kceberle,14 
Marchand,15  Buffet,16  Tedenat,17  etc. 


Fig.  181. — Amputation  of  the  Cervix,    a,  Intra- vaginal  operation;  b,  supra-vaginal  operation,  show- 
ing line  of  incision  and  suture;  oi,  internal  os. 

Combining  the  statistics  of  Hofmeier,  Gusserow,  Baker,  Reamy, 
Wells,  and  Wallace,  we  obtain  221  cases,  with  26  deaths,  or  11.5$; 
those  of  Hofmeier  and  Baker,  which  alone  are  complete  from  this 
point  of  view,  show  more  than  50$  of  cures  after  two  years.  I  find, 
with  Barraud,  that  this  proportion  is  "  truly  too  fine,"  completely 
disagreeing  with  the  general  prognosis  of  cancer.  It  seems  to  me  that 
it  affords  the  best  demonstration  of  the  numerous  errors  of  diagnosis 
which  lie  hidden  in  this  extraordinary  series,  upon  which  many  of 
the  arguments  against  early  hysterectomy  have  been  based. 

In  spite  of  the  ardent  discussions  in  France  and  elsewhere,  sur- 
geons are  not  agreed  in  the  choice  between  total  and  partial  excision, 
and  it  is  probable  that  the  opinion  of  the  majority  of  the  partisans  of 
the  latter  operation  would  be  modified  if  it  were  demonstrated  that 
the  mortality  of  hysterectomy  is  not  sensibly  higher  than  that  of  exci- 
sion of  the  cervix;  however,  this  demonstration  is  to-day  almost  made. 
The  gloominess  of  the  early  statistics  was  due  in  part  to  the  inexperi- 


TREATMENT   OF   CANCER   OF  THE   CERVIX.  359 

ence  of  many  of  the  operators,  the  rjerformance  of  radical  operations 
in  unsuitable  cases,  and  the  absence  of  a  perfect  technique.  Since 
these  causes  of  failure  have  disappeared,  the  mortality  has  fallen  to 
5.88^  in  France.ls  Leopold19  from  1883  to  1889  did  80  vaginal 
hysterectomies  for  cancer,  with  only  4  deaths,  or  5$;  the  last  52 
of  this  series  were  followed  by  cure.  Dmitri  Ott,  of  St.  Petersburg 
had  30  cases  without  a  death.20  These  examples  are  eloquent. 
They  prove  that  by  attacking  cancer  at  the  first  and  performing 
hysterectomy  in  cases  which  used  to  be  treated  by  partial  ex- 
cision, we  obtain  a  mortality  which  does  not  surpass  that  of 
cervical  amputations.  I  cannot  repress  the  thought  that  hsemo- 
stasis  and  antisepsis  are  far  easier  in  total  hysterectomy  than  in  supra- 
vaginal amputation;  and  in  fact  the  last  operations  of  this  kind,  both 
in  and  out  of  France,  have  not  given  more  than  11$  of  deaths.  The 
great  argument  against  early  hysterectomy  is  thus  ruined  and  the 
indications  for  speedy  interference  strengthened.  The  chief  of 
these  appears  to  me  to  be  the  impossibility,  in  the  majority  of  the 
cases,  of  knowing  whether  the  disease  is  circumscribed  or  whether 
it  is  travelling  by  the  mucous  membrane  toward  the  body  of  the 
uterus.  Examinations  by  touch  and  speculum  are  always  uncer- 
tain on  this  point  and  expose  us  to  cruel  mistake.  I  have  recently 
seen  a  case  of  this  anatomical  condition  which  escaped  clinical 
examination  where,  after  performing  total  hysterectomy  for  an 
epithelioma  which  seemed  confined  to  the  lower  part  of  the  cervix 
and  for  which  either  the  high  or  the  low  amputation  appeared  suita- 
ble, it  was  easy  to  determine  on  the  extirpated  tissues  the  presence  of 
a  band  of  neoplasm  reaching  up  toward  the  fundus.21 

A  second,  more  unusual  mode  of  hidden  propagation  where  there 
is  a  small  cancer  in  the  cervix,  is  by  the  formation  in  the  body  of  the 
organ  of  a  series  of  metastatic  nodules  not  admitting  diagnosis  upon  the 
living  patient.  Cases  of  this  kind  have  been  cited  by  Ruge,  Bins- 
wanger,  Diivelius,  Terrier,  Strotz,  and  Abel,22  and,  although  rare,  must 
not  be  neglected.  Let  me  also  call  to  mind  the  observations  of  Abel 
and  Landau  on  serious  changes  in  the  uterine  mucosa  with  epi- 
thelioma of  the  cervix;  for  while  it  is  not  proved  that  these  altera- 
tions are  sarcomatous,  yet  they  undoubtedly  produce  a  locus  minoris 
resistentise  and  favor  recurrence. 


360 


CLINICAL   AND   OPEEATIVE   GYNAECOLOGY. 


III.  Cancer  of  the  Cervix,  with  Extension  to  the  Body  of  the 
Uterus,  without  Invasion  of  the  Adjacent  Tissues. 

In  cases  of  this  character  there  is  but  little  discussion  concerning 
the  best  method  of  treatment,  the  majority  of  gynaecologists  favor- 
ing the  performance  of  total  hysterectomy  by  the  vagina. 

This  operation 23  is  not  of  recent  origin,  having  been  known  for 
nearly  half  a  century  under  the  name  of  colpo-hysterectomy.     It  fell 


B  C  A  F 

Fig.  182. — Various  Models  of  Prehension  Forceps  for  Grasping  the  Cervix  Uteri  in  Hysterectomy. 
A,  E,  Hook  forceps;  B,  D,  flat  with  internal  teeth;  C,  with  blunt  hooks  (Collin) ;  F,  F,  with  gliding  hooks 
(Colhn). 

into  disfavor  on  account  of  its  excessive  mortality  until  recently,  when 
Czerny  prepared  the  vray  for  its  revival,  after  the  greater  dangers  of 
total  extirpation  by  the  abdominal  method  (Freund,  1878)  had  made 
it  necessary  to  seek  other  means  of  relief.24 

Cotyo-hysterectomy  or  Vaginal  Hysterectomy. — Before  operating- 
it  is  necessary  to  make  certain,  by  careful  examination  of  the  patient, 
that  the  uterus  is  movable  and  the  broad  ligaments  free  from 
disease ;  for  this  purpose  bimanual  palpation,  rectal  touch,  and  down- 


TREATMENT   OF   CANCER   OF   THE   CERVIX. 


361 


ward  traction  with  fixation  forceps  are  indispensable.  At  times,  in 
doubtful  cases,  to  overcome  the  contractions  of  the  abdominal 
muscles  and  render  the  tissues  lax,  or  to  eliminate  timidity  in  a 
nervous  patient,  it  is  well  to  make  a  preliminary  examination  under 
chloroform. 

Another  preliminary  precaution  consists  in  as  complete  disinfec- 
tion as  possible  of  the  vagina  for  several  days  before  the  operation. 


Fig.  183. — Relation  of  the  Ureters  and  Uterine  Arteries  to  the  Cervix.  U,  Uterus;  Ur,  ureter; 
A  U,  uterine  artery;  C,  cervix  uteri,  displayed  by  a  transverse  incision  of  the  anterior  vaginal  cul-de-sac; 
V,  section  of  the  bladder  at  the  level  of  the  entrance  of  the  ureters  through  its  walls;  Va,  vagina;  two 
bands  of  fibrous  tissue  are  seen  to  unite  it  laterally  with  the  uterus.  We  can  distinguish  on  the  cervix  the 
part  not  covered  by  peritoneum,  which  adhered  to  the  bladder  before  dissection. 

If  the  cervix  is  covered  with  friable  vegetations  which  are  causing  a 
fetid  discharge,  they  must  be  curetted  a  week  before  we  operate,  with 
a  subsequent  application,  if  necessary,  of  some  hsemostatic  like  chlor- 
ide of  zinc  (1  :  10)  or  the  actual  cautery,  and  then  the  operative  field 
must  be  cleansed  and  guarded  against  infection.  As  this  procedure 
causes  but  little  pain,  it  is  not  necessary  to  employ  ansesthesia. 
Thorough  irrigation  with  sublimate  solution  (1  :  5,000)  twice  a  day, 
and  the  application  of  iodoform  tampons  in  the  interval,  complete  the 
preparation. 


362 


CLIXIOAL   AJSTD   OPERATIVE   GYNAECOLOGY. 


Three  hours  before  the  operation  the  patient  should  take  a  large, 
simple  enema,  and  immediately  beforehand  an  assistant  who  is  not 
to  have  any  part  in  the  hysterectomy  should  determine  by  rectal 
touch  that  the  large  intestine  is  entirely  empty ;  if  it  still  contains 
fecal  matter,  an  injection  of  hot  water  is  at  once  given  and  the  faeces 
removed  with  the  aid  of  the  finger ;  then  the  rectum  is  cleansed  by 
an  injection  of  a  saturated  boric-acid  solution.  The  bladder  is  to  be 
emptied  at  the  beginning  of  the  operation  by  one  of  the  assistants. 


Fig.  184.— Vessels  of  the  Uterus ;  IIterixe  and  Utero-ovarian  Arteries. 


The  patient  is  anesthetized  and  placed  in  the  dorso-sacral  position, 
an  assistant  on  each  side  taking  one  of  the  flexed  thighs  under  his 
arm  while  his  other  remains  free  to  assist.  The  f ourchette  is  depressed 
by  a  univalve  speculum  and  the  lateral  parts  held  aside  by  retractors. 
The  cervix  is  seized  with  Museux  or  other  fixation  forceps  (Fig.  182) 
and  continuous  irrigation  of  the  field  of  oxDeration  gently  begun  (Fig. 
11,  p.  17). 

First  Step.  Opening  Douglas1  Poucli  and  Vagino-peritoneal 
Suture. — The  cervix  is  drawn  strongly  forward  so  as  to  stretch  the 
posterior  vaginal  pouch  as  much  as  possible,  which  is  then  incised 
transversely  down  to  the  peritoneum,  across  its  whole  width. 

The  index  finger  of  the  left  hand  is  passed  into  this  opening,  and 
with  a  strongly  curved  needle  a  series  of  sutures  is  inserted  throughout 


TREATMENT  OF  CANCER  OF  THE  CERVIX. 


363 


the  whole  extent  of  the  section,  taking  in  the  entire  thickness  of  the 
tissues  up  to  the  peritoneum  and  including  it.  By  this  procedure 25 
we  obtain  a  perfect  luemostasis  of  the  vaginal  vessels,  which  are  often 
the  source  of  bleeding  troublesome  by  its  persistence,  and  the  cellular 
interstices  are  closed  and  protected  from  laceration  during  the  subse- 
quent manoeuvres  (Fig.  185). 

It  may  happen  that  the  posterior  vaginal  insertion  is  very  thick, 
or  that  the  cul-de-sac  of  Douglas  is  partially  closed  by  adhesions;  in 
these  instances,  where  the  dissection  must  be  carried  very  high,  it  is 
well  to  insert  two  superimposed  planes  of  suture. 


Fm.  185.— Vaginal  Hysterectomy.    First  step,  opening  the  posterior  cul-de-sac  and  suture  of  the 
peritoneum  to  the  vaginal  mucosa  (Martin). 


Second  Step.  Hemostatic  Sutler e  of  the  Pelvic  Floor  [Ligation 
of  the  uterine  artery], — The  needles  are  now  changed  for  those  which 
are  less  elliptical,  stronger,  and  of  greater  length ;  Deschamps'  pointed 
needles  are  the  best  for  this  special  step.  With  them  two  large 
sutures  are  placed  on  each  side  of  the  opening,  which  include  the 
posterior  part  of  the  lateral  vaginal  pouches  in  mass,  going  deeply  to 
seize  the  inferior  branches  or  the  trunk  of  the  uterine  artery,  at  the 
base  of  the  broad  ligament.  During  this  manoeuvre  it  is  best  to  place 
the  index  finger  in  the  opening,  and  press  the  base  of  the  ligament 
strongly  forward  so  that  it  is  carried  in  front  of  the  needle  (Fig.  186). 


364 


CLINICAL   AND    OPERATIVE    GYNAECOLOGY. 


The  needle  enters  two  centimetres  from  the  angle  of  the  wound, 
while  the  finger  feels  for  its  point,  and  it  emerges  about  one  centi- 
metre from  its  point  of  entry.  Very  strong  silk  is  used  for  this  suture, 
and  tightly  tied.  One  or  two  other  points  are  then  sutured  in  a 
similar  way,  the  first  being  anterior  and  very  near  the  cervix ;  and 
thus  all  the  vessels  are  obliterated  before  the  early  steps  of  the  opera- 
tion are  completed.  There  is  no  danger  of  including  the  ureter,  as  it 
is  situated  more  in  advance,  and  also  is  strongly  drawn  upward  by  the 
traction  upon  the  cervix. 


Fig.  186. — Vaginal,  Hysterectomy.    Second  step,  ligation  of  the  uterine  artery  (Martin). 


Tliird  Step.  Complete  Circumcision  of  the  Vagina  and  Libera- 
tion of  the  Bladder. — The  cervix  is  carried  backward  to  stretch  the 
anterior  cul-de-sac,  and  the. incision  of  the  vagina  completed  in  front, 
using  great  care  to  keep  as  near  the  uterus  as  possible,  so  as  not  to 
injure  the  bladder,  and  yet  to  avoid  the  diseased  tissues.  For  the 
same  reasons  the  edge  of  the  knife  is  to  be  directed  obliquely  toward 
the  cervix.  When  the  vaginal  incision  is  accomplished,  the  knife  is 
laid  aside  and  the  part  dissected  from  the  bladder  with  the  finger; 
occasionally  the  scissors  will  be  needed  for  this  part  of  the  operation. 
We  need  to  remember  that  the  extent  and  strength  of  these  connec- 


TREATMENT  OF  CANCER  OF  THE  CERVIX.  365 

tions  vary  much  in  different  subjects.  At  the  end  of  a  short  interval 
the  finger  appreciates  the  lack  of  resistance  before  it  which  indicates 
that  the  peritoneum  has  been  reached  and  the  limit  of  the  attachment 
of  the  bladder;  the  serous  membrane  may  sometimes  be  seen  at  the 
bottom  of  the  wound,  recognized  by  its  bluish  appearance.  Many 
surgeons  incise  it  at  this  moment,  but  I  prefer  to  wait  so  that  the 
uterus,  when  it  is  inverted,  may  not  carry  the  ulcerated  surface  of  the 
cervix  within  the  cavity.  The  dissection  should  not  be  carried  much 
farther  forward  without  arresting  the  hemorrhage,  which  is  very 
slight,  by  points  of  suture  placed  on  the  cut  surface  of  the  tissues. 

Fourth  Step.  Displacement  Backward  of  the  Uterus  and  Liga- 
tion of  the  Broad  Ligaments. — The  cervix  is  now  free  to  its  upper 
limit.  It  should  be  drawn  well  forward,  while  the  posterior  portion 
of  the  wound  is  Repressed  with  a  single  blade  or  retractor,  and  then 
the  uterus  is  seized  behind  with  a  curved  Museux  forceps  and  made 
to  turn  over  within  the  wound,  the  forceps  on  the  cervix  being  first 
removed. 

At  times  there  is  some  difficulty  in  effecting  this  manoeuvre,  most 
often  because  the  cervix  is  not  entirely  freed  from  its  connections — a 
procedure  which  must  be  completed  as  soon  as  the  ligation  of  the 
pelvic  floor  has  rendered  the  parts  exsanguine. 

Different  instruments  have  been  invented  for  this  inversion  of  the 
uterus;  Martin  employs  a  sound  introduced  into  the  cavity;  Quenu 
uses  a  double-branched  hook ;  I  think  that  all  these  instruments  are 
not  free  from  inconvenience  or  danger.  If,  from  the  presence  of  a 
fibroma  or  an  adhesion  or  some  other  cause,  the  uterus  is  not  easily 
inverted  in  spite  of  liberation  of  the  cervix,  it  is  best  to  draw  it  di- 
rectly down  and  tie  the  broad  ligaments  in  situ.  Muller  has  pro- 
posed to  split  the  organ  in  difficult  cases  and  extract  each  half  sepa- 
rately. 

When  the  uterus  has  been  inverted,  the  superior  portion  of  the 
broad  ligaments  is  found  below  and  their  base  above.  They  should  be 
ligated  in  three  parts  unless  there  is  any  need  of  intercrossing  the 
threads  for  a  chain  suture.  The  left  ligament  is  first  tied  and  cut. 
Before  detaching  the  uterus '  completely  the  last  portion  of  the  liga- 
ment is  to  be  united  by  single  sutures  to  the  commissure  of  the  vagi- 
nal wound.  The  right  side  is  then  treated  in  a  similar  manner,  and 
the  operation  is  terminated  by  severing  the  last  bands  which  retain 
the  uterus,  particularly  the  peritoneum  of  the  anterior  cul-de-sac 
which  has  been  so  far  retained  as  a  barrier  against  possible  infection 


366  CLINICAL   AND    OPERATIVE    GYNAECOLOGY. 

from  the  inverted  cervix.  The  wound  is  then  cleansed  with  great  care 
by  small  tampons  of  antiseptic  cotton. 

Fiftli  Step.  Drainage  and  Dressing. — One  point  of  suture  in 
each  commissure  of  the  vaginal  wound  diminishes  it  enough  without 
closing  it  entirely.  Before  tying  the  threads,  I  place  in  the  retro- 
peritoneal pouch  a  piece  of  iodoform  gauze,  doubled,  to  act  as  a  drain, 
its  two  ends  being  rolled  up  in  the  vagina  and  tied  with  a  thread  so 
that  they  may  be  recognized.  Other  pieces  of  the  gauze,  lightly 
packed,  complete  the  dressing.  It  is  to  be  renewed  according  to  the 
amount  of  serous  or  bloody  oozing,  leaving  in  place  the  strip  of  gauze 
in  the  cul-de-sac  to  perform  the  office  of  a  drain ;  the  latter  is  not  re- 
moved till  the  end  of  six  to  eight  days. 

I  much  prefer  this  mode  of  drainage  to  the  rubber  tube  in  the 
form  of  a  cross  which  Martin  uses,  or  the  glass  tube  ojE  English  writers, 
or  the  double  tube  coupled  like  a  gun  barrel  of  certain  French  sur- 
geons.26 As  to  the  complete  occlusion  of  the  wound,  it  was  advocated 
by  Mikulicz  at  the  Surgical  Congress  of  Berlin  in  1881,  but  to-day  it 
has,  with  good  reason,  very  few  partisans,  other  than  Hegar  and 
Kaltenbach.27 

The  next  question  to  be  decided  is  as  to  the  removal  of  the  adnexa. 
If  the  ovaries  and  tubes  are  prolapsed  into  the  wound,  they  should  be 
excised,  but  when  they  must  be  searched  for,  the  indications  differ 
according  as  the  woman  has  or  has  not  reached  the  menopause;  in 
the  latter  case  it  is  necessary  to  remove  organs  whose  function  might 
continue  for  some  time  (for  ablation  of  the  uterus  does  not  always 
produce  ovarian  atrophy)  and  thus  give  rise  to  accidents.28  We  pro- 
ceed then  rapidly  to  search  for  the  adnexa,  whose  removal  is  gen- 
erally easy.  If  there  is  much  difficulty,  but  little  time  should  be  lost 
over  this  manoeuvre.  Brennecke  has  reached  the  conclusion  that  in 
view  of  their  final  atrophy  removal  of  the  adnexa  is  of  comparatively 
little  importance — an  opinion  which  is  apparently  contradicted  by  the 
experiments  of  Grammatikati  and  Glaevecke,29  which  indicate  that  the 
function  of  the  ovaries  continues  but  is  tolerated  by  the  peritoneum. 

The  final  treatment  is  very  simple.  If  the  iodoform  tampons  are 
not  saturated  with  blood,  they  are  left  in  place  four  days;  then  they 
are  removed.  The  strip  which  acts  as  a  drain  is  withdrawn  at  the  end 
of  the  first  week,  for  the  peritoneal  wound  has  then  long  been  closed 
by  exudation.  It  is  none  the  less  necessary  to  be  very. careful  in  the 
use  of  vaginal  injections— not  to  employ  them  under  eight  days  and 
then  with  but  little  pressure,  keeping  the  fourchette  depressed  (subli- 


TREATMENT  OF  CANCER  OF  THE  CERVIX.  367 

mate  1  :  5,000).  The  patient  may  leave  her  bed  at  the  end  of  three 
weeks,  and  at  about  the  same  time  the  points  of  silk  suture  at  the 
bottom  of  the  vagina  should  be  removed.  This  usually  requires  two 
sessions,  at  intervals  of  a  few  days,  before  it  is  accomplished.  It  is 
not  well  to  neglect  them,  because  they  produce  a  purulent  discharge 
during  their  spontaneous  elimination.  For  the  first  twenty-four 
hours  the  patient  takes  nothing  but  a  little  ice,  to  control  vomiting  from 
the  chloroform.  At  the  end  of  the  third  day  I  give  a  laxative  enema. 
Convalescence  should  be  without  any  elevation  of  temperature. 

This  operative  technique,  which  I  have  adopted  and  which  differs 
but  little  from  that  of  Martin,  is  the  one  that  I  recommend,  though  I 
will  also  describe  certain  modifications  of  the  execration  which  the 
names  of  their  authors  have  invested  with  a  certain  authority. 

Modifications  of  the  First,  Second,  and  Third  Steps. — Fritsch 30 
begins  by  a  dissection  of  the  lateral  cul-de-sac,  searching  for  the  ute- 
rine artery  and  tying  it;  then  he  proceeds  to  the  dissection  of  the  blad- 
der, and  ends  by  the  incision  of  the  recto-vaginal  pouch.  Olshausen 31 
defers  the  opening  of  the  cul-de-sac  as  long  as  possible,  for  fear  of 
infecting  the  peritoneum.  Schatz 32  reserves  the  separation  from  the 
bladder  for  the  final  step.  Sanger  and  other  authors  advise  the 
operator  to  open  the  vaginal  pouches  by  means  of  the  actual  cautery, 
but  this  makes  subsequent  dissection  difficult,  and  is  without  real  ad- 
vantage. To  prevent  hemorrhage  from  the  ulcerated  surface  of  the 
cervix,  Fritsch  places  an  elastic  ligature  ait  its  base  before  dissecting. 
Miiller  compresses  the  abdominal  aorta  during  the  operation. 

It  is  sometimes  necessary  in  cases  with  very  narrow  vagina  or  in- 
troitus,  as  from  the  presence  of  the  hymen,  from  senile  atrophy  or 
circular  bridles,  to  obtain  greater  working  room  by  incising  the  peri- 
neum and  afterward  suturing  it.  I  have  obtained  great  assistance 
from  this  procedure. 

For  fixation  of  the  cervix,  which  is  so  easily  torn,  many  different 
forms  of  forceps  have  been  invented.  Brennecke's  model 33  is  intro- 
duced into  the  cavity  of  the  cervix,  and  then  the  hooks  are  made  to 
project  and  implant  themselves  in  the  healthy  tissue,  so  that  there 
is  no  fear  of  their  tearing  out.  The  Museux  forceps  which  are  ex- 
actly apposed,  and  the  bullet  forceps  seem  to  me  to  be  sufficient. 
Miiller34  after  ligation  of  the  broad  ligaments  in  mass,  divides  the 
uterus  into  halves,  and  other  authors  advise  its  removal  by  fragments ; 
all  such  methods  lead  to  infection  of  the  wound. 

Modifications  of  the  Fourth  Step. — Billroth,  Leopold,  and  Ols- 


368  CLINICAL   AND    OPEKATIVE   GYNAECOLOGY. 

hausen  do  not  employ  the  inversion  of  the  uterus,  but  by  strong  trac- 
tion pull  down  the  organ  and  detach  it  by  degrees,  carefully  ligating 
each  portion  of  tissue  before  dividing  it,  thinking  that  the  inversion 
leads  to  infection  of  the  wound;  but  this  danger  is  almost  wholly  pre- 
vented if  the  cervix  has  been  curetted  and  disinfected  several  days 
before  the  operation,  and  if  the  anterior  peritoneal  pouch  is  preserved 
till  the  last  to  act  as  a  barrier.  Czerny,  Fritsch,  and  Demons  revolve 
the  uterus  forward — a  procedure  which  is  rendered  easy  by  the  fre- 
quent presence  of  anteflexion  and  the  fact  that  the  resistance  of  the 
round  ligaments  does  not  have  to  be  overcome.  Martin  and  Schroder 
reverse  the  uterus  posteriorly,  and,  as  I  have  said,  Martin  in  difficult 
cases  introduces  a  kind  of  mandrel  into  its  cavity  for  the  purpose, 
and  Quenu  has  proposed  a  special  form  of  hook  for  the  same  object. 

For  hsemostasis  of  the  broad  ligaments,  Olshausen  employs  the 
elastic  ligature,  making  an  opening  in  the  peritoneum  with  a  blunt 


Fig.  187.— Bowed  Forceps  for  Compression  of  the  Broad  Ligaments  in  Vaginal  Hysterectomy 

(Doyen). 

bistoury  and  passing  the  elastic  band  with  a  Deschamps  [Peaslee's] 
needle.  Hegar  and  Kaltenbach 35  also  recommend  provisional  elastic 
ligature  of  the  ligaments  in  mass,  securing  permanent  heemostasis  by 
partial  silk  ligatures  as  soon  as  the  uterus  is  detached.  This  I  con- 
sider a  useless  complication.  C.  E.  Jennings 36  has  made  a  provisional 
ligature  of  the  ligaments  in  mass  with  a  loop  of  carbolized  silk,  fas- 
tened with  the  aid  of  a  perforated  shot  which  is  crushed;  he  then 
uses  either  ligatures  or  permanent  forceps. 

Pean  aj)plies  forceps  to  the  ligaments.  Bichelot 37  generally  em- 
ploys permanent  forceps  in  all  cases.  Various  forms  of  forceps  have 
been  proposed;  long  ones  by  Spencer  Wells;  curved  on  the  side  by 
Pean-Richelot  (Fig.  50);  a  disjointable  form  by  Doleris;  Doyen's 
model  (Fig.  187),  a  kind  which  is  curved  so  that  they  compress  only 
with  their  points ;  Polk's  clamps,  etc.38  A  great  number  of  surgeons, 
especially  in  France,  have  adopted  this  operative  procedure,  which  is 
objectionable  for  many  reasons,  of  which  the  chief  are:  the  absence 


TREATMENT    OF    CANCER   OF   THE    CERVIX. 


369 


of  secure  hremostasis,  possible  injury  to  the  bladder,  ureter,  or  intes- 
tine [greater  risk  of  intestinal  adhesion],  and  finally  the  obstacle 
which  it  presents  to  complete  antisepsis.39 

Modifications  of  the  Fifth  Step. — With  the  object  of  preventing 
recurrence  by  free  excision  of  the  adjacent  tissues,  it  has  been  pro- 
posed to  terminate  the  hysterectomy  by  cutting  away  a  part  of  the 
vagina  or  of  the  broad  ligaments.  Bichelot 40  advises  the  first,  even 
when  the  vaginal  wall  is  healthy,  as  a  complementary  step  which  is 
easily  executed  at  the  end  of  the  operation.     Pawlik41  still  more 


Fig.  188.— Vaginal  Hysterectomy.    Application  of  forceps  and  section  of  the  base  of  the  broad 

ligament  (Pean). 

boldly  extirpates  the  parametrium,  after  placing  sounds  in  the  ureters 
so  that  they  may  be  recognized  and  avoided ;  he  has  operated  three 
times  in  this  manner,  but  his  final  results  are  not  published.  It  is 
doubtful  whether  these  modifications  are  really  useful,  and  it  is  cer- 
tain that  they  are  more  or  less  dangerous. 

The  question  of  drainage  is  not  definitely  settled.  In  France  the 
majority  of  operators  leave  the  wound  open  and  introduce  one  or  two 
rubber  tubes.  In  England  glass  tubes  are  more  used.  Martin  em- 
ploys a  rubber  tube  made  in  the  form  of  a  cross,  which  has  the  advan- 
tage of  being  easily  retained  in  place,  and  removes  it  on  the  third  or 
fourth  day.    But  in  Germany  most  surgeons  close  the  peritoneal 

24 


370 


CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 


wound;  Kaltenbacli,  Mickulicz,  Tauffer,  v.  Teuffel,  Schede,  etc.,  de- 
clare in  favor  of  this  method,  while  Czerny  and  Fritsch  reject  the 
suture.  I  think  with  Demons,  Bouilly,  Terrier,  and  almost  all  French 
surgeons  that  it  is  more  prudent  not  to  close  the  wound  completely, 
but  to  diminish  it.  The  discharge  of  serum  and  blood  which  is  so  fre- 
quent in  the  first  few  hours  shows  that  this  is  not  an  unnecessary 
precaution,  for  in  spite  of  all  our  care  the  wound  may  be  infected 
with  cancerous  material. 

Decortication  of  the  uterus,  the  old  method  of  Langenbeck,  who 
operated  thus  on  a  prolapsed  uterus  in  1813,  has  been  revived  by  cer- 


■F' 


Fig.  189.— Vaginal  Hysterectomy.    Forcipressure  of  the  superior  border  of  the  broad  ligament  after 

inversion  of  the  uterus  (Pean). 

tain  authors,  among  whom  are  Lane 42  and  Frank.43  It  is  only  a  use- 
less complication. 

Operative  Accidents.— I  have  already  spoken  of  hemorrhage  and 
the  means  of  avoiding  it. 

The  ureter  may  be  wounded  by  the  bistoury,  a  ligature,  or  the 
grasp  of  a  forceps ;  it  is  also  in  great  danger  from  forcipressure.  As 
it  has  been  included  in  the  forceps  of  very  distinguished  operators,  it 
is  evidently  the  method  and  not  the  operator  which  should  be 
blamed ; 44  when  the  accident  is  not  mortal,  it  usually  ends  in  the  es- 
tablishment of  a  ureteral  fistula. 

To  avoid  such  injury  to  the  ureter  we  must  keep  very  near  to  the 


TREATMENT   OF    CANCER   OF    THE    CERVIX.  371 

cervix,  the  uterus  should  not  be  inverted  until  it  is  freed  from  its 
attachments  up  to  the  peritoneum,  and,  lastly,  no  long  forceps  should 
be  deeply  placed  on  the  broad  ligament.45 

The  bladder  has  been  opened  by  the  bistoury  and  torn  through  by 
the  finger,  the  accident  being  almost  unavoidable  if  the  operation  is 
performed  for  cancer  with  large  extension  anteriorly  (which  should 
contra -indicate  any  operation).  We  must  never  forget  to  catheter- 
ize  the  patient  at  the  beginning  of  the  operation  and  so  make  certain 
that  the  bladder  is  empty  and  least  liable  to  injury. 

"When  the  bladder  has  been  cut  or  torn,  it  must  be  immediately 
closed  Avith  sutures.  Such  cases  have  recovered  without  fistula,  and, 
if  not,  they  are  easily  treated  later.  In  every  case  a  soft  catheter  is 
to  be  retained  in  the  bladder  for  several  days. 

The  rectum  should  not  be  opened  except  by  an  actual  fault  of  the 
operator,  unless  it  is  invaded  by'the  disease,  in  which  case  the  radi- 
cal operation  would  be  more  injurious  than  useful.  It  has  been 
wounded  by  the  forceps,  both  by  being  seized  in  their  jaws  and  from 
simple  pressure  effects.46 

Mortality. — The  mortality  has  fallen  considerably  during  the  last 
few  years.  In  188-1  F.  Brunner 4T  collected  in  his  inaugural  disserta- 
tion all  the  cases  then  published  and  found,  before  1877,  33  cases  with 
82$  of  deaths,  and,  after  1877  till  February,  1884,  146  cases  with  32.9$, 
of  deaths.  Munde,48  in  255  cases  from  both  continents  since  1879  (the 
time  when  Czerny  made  known  his  operation)  up  to  1884,  found  72 
deaths,  or  28$.  W.  A.  Duncan,49  in  276  cases  since  the  beginning  of 
1885,  found  28.6$;  and  Hache,30  who  used  the  excellent  tables  of  S. 
Post 51  with  good  effect,  and  added  other  cases,  bringing  the  record  up 
"to  the  beginning  of  1887,  gives  for  this  period  a  mortality  of  24.47$. 

These  figures  have  only  a  historical  interest,  for,  in  order  to  appre- 
ciate the  gravity  of  colpohysterectomy,  we  must  eliminate  the  older 
cases  and  confine  ourselves  to  those  of  later  years,  where  the  tech- 
nique was  perfected  and  the  operators  had  acquired  a  large  experi- 
ence. It  is  just,  also,  in  an  exact  estimate,  not  to  include  isolated 
cases  by  surgeons  more  or  less  incompetent.  In  the  statistics  of  Dun- 
can (1885)  there  were  276  cases  of  seventy-one  operators,  and  thirty- 
five  of  these  surgeons  had  performed  the  operation  but  a  single  time. 
With  such  elements  we  are  likely  to  obtain  the  inherent  mortality  of 
the  operators  and  not  of  the  operation.  The  rule  established  by  Tait 
seems  reasonable ;  it  consists  in  adopting  as  the  criterion  the  results 
of  surgeons  of  average  ability  and  experience,  and  thus  all  new  opera- 
Hons  should  be  judged. 


372  OLTNICAL    AND    OPERATIVE    GYNAECOLOGY. 

Following  tliis  rule,  Martin 52  obtained  the  list  given  below  of  opera- 
tions up  to  the  end  of  1886 : 

Fritsch 60  operations  "with    7  deaths,  10.1^ 

Leopold 42  "  "        4        "         % 

Olshausen 47  "      12 

Schroder  and  H of meier 74  "  "      12 

Staude 22  "  "        1        " 

A.  Martin 66  "  "      11        " 

311  47  about  15# 

But,  as  I  have  said  above,  these  results,  though  recent,  are  still  too 
ancient  for  our  purpose.  The  latest  statistics  which  I  have  examined 
give  5$  as  about  the  correct  mortality;  the  last  series  of  80  operations 
which  Leopold  had  gave  4  deaths,  or  5/c ; 5a  Kaltenbach,  in  53  cases,  had 
2  deaths,  or  4$ ; 54  D.  de  Ott  is  still  more  fortunate,  having  operated 
thirty  times  without  a  single  death; 55  and  the  same  is  true  of  25  con- 
secutive cases  of  Pean's  which  were  successful.56  After  these  figures, 
there  is  no  need,  it  seems  to  me,  of  further  discussion  as  to  whether 
this  operation  is  applicable  to  every  case  where  cancer  has  been  diag- 
nosed. It  cannot  be  denied  that  we  may  thus  perform  a  radical  oper- 
ation; why,  therefore,  should  it  not  be  adopted,  since  it  is  as  benign 
as  the  partial  operation?  Consequently  there  is  to-day,  on  the  part 
of  many  surgeons,  a  reaction  against  amputations  of  the  cervix 
in  cancer:  Schatz,  Gusserow,  Martin,  Kaltenbach,  Sanger,  Fritsch, 
C.  Fenger,  Bouilly,  Terrier,  etc.,  have  thus  expressed  themselves 
categorically.  I  also  believe  that  hysterectomy  is  the  operation  of 
election  when  the  diagnosis  of  cancer  is  certain.  Therefore  I  have 
written 5T  (without  always  having  been  understood 58),  "  the  more  lim- 
ited the  disease,  the  more  extensive  should  be  the  operation.*'  In 
thus  removing  the  whole  of  the  uterus,  the  result  is  certain,  there  is 
no  opportunity  for  the  disease  to  recur  locally,  and  we  avoid 
also  ganglionic  engorgement  and  invasion  of  the  adjacent  tissues, 
both  of  which  have  occurred  where  the  treatment  has  been  palliative 
and  only  partial  destruction  attempted.  In  other  words,  we  simply 
apply  here  the  rules  which  are  accepted  for  external  or  general  cancer. 

Causes  of  Death  after  Vaginal  Hysterectomy. — These  maybe 
arranged  under  three  principal  heads — hemorrhage,  shock,  and  septi- 
caemia. 

Hemorrhage  may  occur  during  or  after  operation.  Primary  hem- 
orrhage is  always  the  result  of  an  operative  fault,  and  may  be  cer- 
tainly avoided  by  ligating  the  tissues  step  by  step  in  small  portions 
before  they  are  divided.     We  should  also  avoid  any  traction  upon  a 


TREATMENT  OF  CANCER  OF  THE  CERVIX.  373 

ligature  when  it  is  once  tied,  and  for  this  reason  the  ends  of  the 
thread  should  always  be  cut  at  first,  instead  of  saving  them  until  the 
end  of  the  operation.  Progressive  ligature  exposes  less  to  risk  of 
hemorrhage  than  the  use  of  forceps.  If  a  ligature  slips,  but  one  or 
two  vessels  bleed.  If  the  tissues  become  disengaged  from  a  long  for- 
ceps, the  greater  part,  if  not  the  whole,  of  the  broad  ligament  retracts 
and  gives  rise  to  free  hemorrhage.  There  are  many  cases  of  death 
after  the  systematic  use  of  forceps  from  this  cause,  of  which  I  will  cite 
only  that  of  Bichelot 59  occurring  in  the  service  of  Professor  Verneuil, 
and  one  other  in  my  own  practice  which  I  have  not  yet  published. 

Secondary  or  rather  continuous  hemorrhage  has  been  observed  in 
cases  of  excision  for  cancer  where  the  parts  adjacent  to  the  uterus 
were  involved  and  all  of  the  disease  could  not  be  removed.60 

In  case  of  secondary  bleeding,  which  is  a  comparatively  rare  acci- 
dent, the  vagina  should  be  packed  with  tampons  of  resin-iodoform 
gauze  if  the  hemorrhage  is  not  alarming.  If,  however,  it  is  dangerously 
free,  the  bleeding  vessel  should  be  found  and  tied  or  controlled  with 
forceps  (forcipressure  of  necessity). 

Shock. — Under  this  vague  and  general  name  are  grouped  factors 
the  most  diverse.  In  the  first  place,  exhaustion  from  a  hemorrhage 
whose  importance  has  escaped  the  attention  of  the  operator  maybe 
one  of  the  causes  of  the  accident,  for,  unless  the  haemostasis  has  been 
carefully  performed  step  by  step,  certain  vessels  may  bleed  contin- 
uously during  the  whole  of  the  operation,  and  this  condition  is  the 
more  serious  when  the  patient  has  been  already  exhausted,  or  when  it 
continues  for  a  long  time. 

Another  cause  of  shock  is  acute  uraemia,  depending  upon  alteration 
of  the  kidneys.  It  is  well  known  how  frequently  compression  of  the 
ureters  causes  disease  of  these  organs.  Many  cancerous  patients  live 
with  the  minimum  of  uropoietic  function  in  a  kind  of  unstable  equi- 
librium, and,  if  this  precarious  condition  is  overbalanced  by  some  dis- 
turbance, the  uraemia  which  has  been  threatening  develops  with  great 
rapidity.  Thus  the  chloroform  [or  especially  ether]  absorbed  during 
the  time  of 'anaesthesia  may  during  its  elimination  by  the  kidney  cause 
a  fatal  congestion  of  these  organs ;  hence  the  mortality  of  prolonged  nar- 
cosis. The  uraemia  may  be  due  to  absorption  of  the  wound  secretions, 
whose  elimination  encumbers  the  renal  filter  and  monopolizes  the  small 
portion  of  healthy  tissue  which  sufficed  for  the  normal  requirements  of 
the  economy.  Many  cases  of  death  from  so-called  shock  are  plainly 
due  to  uraemia,  generally  of  the  comatose  form,  as  appears  both  from 


374 


CLINICAL  AND   OPERATIVE   GYNAECOLOGY. 


the  clinical  details  and  from  the  autopsy  records.  It  may  also  have 
been  caused  by  the  unfortunate  application  of  a  ligature  to  an  unrec- 
ognized ureter.  To  avoid  such  accidents,  we  should  never  perform 
hysterectomy  on  a  patient  who  presents  symptoms  of  albuminuria  or 
whose  urine  contains  a  largely  diminished  quantity  of  solids.  If, 
however,  in  spite  of  unfavorable  conditions,  we  decide  to  operate,  the 
gravity  of  the  prognosis  should  be  recognized  and  the  operation  be 
performed  as  quickly  as  possible  with  the  shortest  convenient  dura- 
tion of  the  anaesthesia.  I  keep  my  patients  on  a  milk  diet  for  the 
first  few  days  after  the  operation,  quite  as  much  to  facilitate  diuresis 
as  to  supply  aliment. 

Septiccemia. — One  of  the  chief  causes  of  this  accident  is  the  infec- 
tion of  the  wound  in  its  deeper  portions  by  either  the  fluids  or  the 
debris  of  the  cancer.  This  condition  may  be  escaped  by  following 
the  rules  which  I  have  described  and  advised — preliminary  curetting, 
scraping  the  fungous  portions,  continuous  irrigation  during  the  opera- 
tion, preservation  of  a  protective  barrier  between  the  reversed  cervix 
and  the  peritoneal  cavity,  extraction  of  the  uterus  entire  without 
morcellation,  rejection  of  permanent  forceps  which  cause  mortification 
of  the  tissues,  and  rigorous  antisepsis. 

Survival  after  Hysterectomy.— Although  the  operation  is  of  very 
recent  date,  a  number  of  reports  have  been  collected  upon  the  subject, 
the  most  extensive  of  which  is  that  furnished  by  Hache.61  A  resume 
is  given  in  the  following  table,  which  I  cannot  reproduce  without  re- 
marking that  it  unfortunately  refers  to  a  series  of  relatively  ancient 
cases  of  operation  where  it  was  performed  too  late,  with  no  real  chance 
of  permanent  success.  It  gives,  therefore,  too  gloomy  an  idea  of  the 
actual  results,  but  it  is  a  valuable  document  by  which  to  appreciate 
the  progress  accomplished  since  1866. 

Ultimate  Result  in  150  Cases  after  Hysterectomy. 


Time  since  operation. 

Lost  to  view  before 
recurrence. 

Dead,  or  with 
return. 

With  no  recur- 
rence. 

5 
6 
5 

'     2 
10 
14 
21 
10 

23 

20 

10 

9 

8 

0 
0 
1 

122 

6        "       

96 

9        "       

81 

12         " - - 

70 

18        " 

52 

38 

3       "     

17 

4      "     

6 

By  these  figures  we  may  appreciate  approximately  the  proportion 
of  survivals  and  recurrences  in  one  hundred  operations  during  what 


TREATMENT   OF   CANCER   OF   THE   CERVIX. 


375 


may  be  called  the  initial  period  of  hysterectomy  (up  to  1886).  To 
determine  this  proportion,  it  is  necessary,  as  Hache  asserts,  to  consider 
all  patients  lost  to  view  less  than  a  year  after  operation  as  having  had 
a  return  of  the  disease  immediately  after  their  last  examination.  For 
those  which  were  observed  more  than  a  year,  Hache  includes  among 
recurrences  a  majority  of  those  who  have  been  consequently  lost  to 
view.  The  following  results,  therefore,  may  be  considered  a  very  pes- 
simistic interpretation  of  the  preceding  statistics : 

In  100  Cases. — Twenty  three  succumbed  to  operation;  in  15  the 
disease  returned  in  the  first  three  months ;  in  13  between  three  and  six 
months — which  is  28  in  the  first  half  year;  in  13  between  six  and 
twelve  months,  that  is,  13  in  the  second  semester;  in  10  between  one 
and  two  years;  in  10  in  the  second  year;  26  were  still  in  good  health 
at  the  end  of  two  years. 

In  determining  what  per  cent  of  the  patients  had  a  recurrence  in 
the  number  of  those  who  survived  at  the  end  of  each  of  these  periods, 
Hache  found  that  the  chances  of  return  were  about  equal  during  the 
first  two  periods  of  nine  months,  with  a  gradual  decrease  thereafter. 
This  result  is  evidently  due  to  incomplete  operation  and  the  imme- 
diate return  of  a  neoplasm  which  has  been  simply  resected.  There  is 
still  another  factor,  which  is  the  very  rapid  course  of  certain  cancers, 
especially  in  young  women.  As  a  striking  example  of  this,  two  pa- 
tients of  Tillaux  and  one  of  Tedenat  had  a  return  of  the  disease  at  the 
end  of  six  weeks,  three  months,  and  five  months.  I  have  observed  a 
case  of  rapid  return  in  a  woman  of  thirty-eight  years  with  a  tubular 
epithelioma  of  the  cervical  cavity ;  the  origin  of  the  disease  seemed  to 
have  been  only  five  months  before  the  operation,  and,  although  the 
diseased  portions  were  entirely  removed,  the  return  was  very  rapid, 
and  the  patient  succumbed  five  months  after  the  hysterectomy.62 

A  valuable  report  is  given  by  A.  Martin  in  the  memoir  Avhich  I 
have  cited.  In  the  series  which  he  reports  is  included  the  practice  of 
certain  German  gynaecologists  up  to  the  end  of  1886,  with  the  follow- 
ing results  as  regards  survival  without  return : 


Eecurrence. 

Leopold. 
56  cases. 

Schroder, 
62  cases. 

Fritsch, 
53  cases. 

Martin, 
56  cases. 

In  2*    "    

16 
9 
5 
2 

20    . 
10 

7 
4 

17 

"l 
2 

35 
32 
25 
20 
5 

In  3       "    

In  4        "    .-. 

In  5        "    

3 
2 

In  6        "    

376  CLIISTICAL  AjS^D  operative  gynecology. 

Percentages  derived  from  the  above  table : 

Recurrence  at  end  of  1  year 42.3$ 

"        "  li  years 32.9* 

"  "        "  2        "     21.15* 

"3        "     13.41* 

"4        "     2.4* 

The  operations  performed  in  France  are  of  too  recent  a  date  for 
ns  to  establish  an  analytical  table.  Bonilly,  in  29  cases,  had  23  cures, 
of  which  one  had  had  no  return  after  two  years,  one  after  fourteen 
months,  and  one  after  five  months  and  a  half;  13  cases  of  return  have 
been  observed  less  than  a  year  after  operation.  Kichelot,  in  24  cases, 
had  15  cnres,  among  which  were  eight  rapid  returns,  one  cure  after 
twenty-five  months,  one  after  twenty-three  months,  one  after  eighteen 
months,  one  after  fourteen  months ;  the  others  have  not  yet  lasted  a 
year.  In  my  own  series  of  seven  cases,  I  have  had  one  cure  lasting 
'two  years  and  a  half,  and  one  case  after  one  year  and  a  half  enjoyed 
perfect  safety;  twice  there  has  been  rapid  return  within  the  year. 
The  most  important  series  which  has  been  recently  published  is 
that  of  Leopold,63  relating  to  80  vaginal  hysterectomies  for  cancer,  in 
which  only  4  died  after  operation,  and  comprising  the  results  of  his 
practice  during  five  years  and  half.  Among  the  76  cures,  14  have  since 
died,  among  which  only  10  were  due  to  return  of  the  cancer  and  4  to 
other  causes ;  in  the  62  surviving  patients,  only  3  presented  a  return ; 
the  others  remained  cured  for  a  variable  time.  It  is  seen  also  that  27 
cases  remained  free  from  return  two  years  or  more  among  80  opera- 
tions; but  subtracting  the  4  deaths  from  accidental  diseases,  we  have 
the  figure  76  as  the  more  exact.number. 

Hofmeier,  taking  the  end  of  the  second  year  to  establish  the  value 
of  total  extirpation,  according  to  Schroder's  operations,  obtained  the 
figure  24$  as  representing  the  proportion  of  complete  cures,  but,  as 
return  of  the  disease  is  always  to  be  feared,  it  is  an  illusion,  I  think, 
to  speak  of  definite  cure  of  cancer  of  the  uterus  more  than  in  the 
case  of  any  other  malignant  neoplasm.  It  is  not  the  less  correct  to 
perform  hysterectomy  just  as  we  practise  amputation  of  the  breast 
and  dissection  of  the  axilla,  of  which  the  prognosis  is  certainly  more 
grave;  a  return  is  always  to  be  feared  in  either  case,  but  a  temporary 
respite  is  still  a  benefit. 

It  is  interesting  to  examine  the  reports  of  survival  after  partial 
operation  (supra-  and  infra-vaginal),  and  to  compare  them  with  those  of 
total  ablation  of  the  uterus.     But  before  reporting  on  the  principal 


TREATMENT   OF   CANCER   OF   THE   CERVIX.  377 

documents  which  we  possess  on  the  subject  I  must  remark  that  this 
unequal  parallel  should  not  be  made  the  basis  of  conclusions  without 
some  reservation.  In  what  cases  do  we  always  amputate  the  cervix  ? 
For  cancer  at  its  beginning.  In  what  cases  do  we  ordinarily  perform 
hysterectomy?  For  cancers  which  are  well  advanced,  having  already 
reached  the  body  of  the  organ.  In  the  first  case,  there  are  many 
chances  that  the  disease  has  not  infected  the  lymphatics,  but  very  few 
in  the  second.  Why  should  we  then  be  surprised  if  return  is  less 
rapid  where  amputation  of  the  cervix  has  been  so  fortunate  as  to  re- 
move all  of  the  disease?  But  who  shall  say  that  all  the  cases  of  per- 
manent cure  would  not  have  been  increased  in  number  if  those  treated 
by  partial  operation  had  been  submitted  to  total  ablation  of  the 
organ  ? 64  May  not  those  cases  be  unrecognized  where,  with  appear- 
ance of  the  disease  limited  to  the  cervix,  the  mucous  membrane  of  the 
body  is  invaded  by  propagation,  and  also  those  where  the  uterine 
parenchyma  contains  distant  secondary  nodules  ? 

The  comparison  which  we  would  like  to  establish  between  the  re- 
sults of  partial  and  total  ablation,  as  regards  permanence  of  cure, 
would  not  be  a  just  one  unless  it  were  derived  from  two  series  of 
patients  in  exactly  similar  conditions,  with  affections  of  equal  devel- 
opment. But  how  shall  we  construct  such  a  parallel  with  the  aid  of 
published  series  of  total  hysterectomies  which  refer  in  the  great 
majority  of  cases  to  disease  which  has  passed  freely  beyond  the  cer- 
vix, which  appear  in  the  list  of  the  less  serious  cases,  and  yet  which 
render  the  final  table  discouraging  ?  For  this  reason  I  have  thought 
that  the  value  of  the  actual  statistics  on  this  special  point  should  be 
contested.63 

The  most  important  papers  on  the  subject  are  those  of  Schroder- 
Hofmeier  and  of  Verneuil. 

The  first  in  date,  and  not  the  least  curious,66  is  the  former,  which 
gives  all  the  total  hysterectomies  and  partial  amputations  of  Schroder's 
clinic  from  1878  to  1886.  The  following  table  gives  the  comparative 
number  permanently  cured  by  the  two  methods: 

At  the  end  of  1st  year,  Partial  operation,  114  cases,  49  cures 51$ 

Total  hysterectomy,  46  cases,  20  cures 63.6$ 

"    2d       "     Partial  operation,  102  cases,  38  cures  46$ 

Total  hysterectomy,  40  cases,  7  cures 24% 

"    3d       "     Partial  operation.  76  cases,  24  cures  42% 

Total  hysterectomy,  31  cases,  6  cures 26% 

"    4th      "    Partial  operation,  59  cases,  19  cures 41.3$ 

Total  hysterectomy,  18  cases,  0  cures 0% 


378  CLINICAL   AND    OPERATIVE    GYNECOLOGY. 

It  is  evident  that  an  enormous  advantage  lies  with  the  second  year 
after  amputation  (supra-  and  intra-vaginal  taken  together);  at  the 
end  of  three  years  24  patients  out  of  76  had  no  return  of  the  disease, 
and  at  the  end  of  4  years  19  out  of  39 :  but  may  that  not  be  due  sim- 
ply to  the  fact  that  they  were  operated  upon  before  the  lymphatics 
were  infected  \ 

The  results  of  Yerneuil  are  no  less  remarkable.67  The  intra-va- 
ginal operation  with  the  ecraseur,  in  his  hands,  gave  the  following  pro- 
portion of  recurrence  and  periods  of  respite :  In  21  operations  there 
were  10  cases  of  rapid  return;  in  more  than  9  of  these  Yerneuil  recog- 
nized by  immediate  examination  that  the  ablation  had  not  been  "com- 
plete. In  6  other  cases  there  was  no  return  up  to  the  time  when  the 
patient  was  lost  to  observation  in  perfect  health,  three  years  and  more 
after  the  operation.  Two  cases,  which  are  still  alive  but  afflicted  with 
a  return  in  a  distant  part,  presented  an  apparent  recovery  after  three 
years.  Lastly,  in  3  cases,  the  patients  were  actually  in  good  health 
after  five  years,  seventeen  months,  and  three  months. 

In  contrast  to  this  series,  which  appears  to  prove  the  therapeutic 
superiority  of  the  partial  operation,  the  results  of  Martin's  exrjerience 
should  be  cited.68  A  pupil  of  the  school  of  Schroder,  he  began  to 
perform  supra-vaginal  amputation  of  the  cervix  in  cases  of  epithe- 
lioma where  it  was  theoretically  indicated,  but  his  results  were  de- 
plorable: Among  twenty-eight  patients,  two  alone  remained  without 
recurrence.  He  then  adopted  early  hysterectomy,  with  decided  im- 
provement in  his  ultimate  results. 

In  the  presence  of  such  contradictions,  and  the  absence  of  rigorous 
means  of  comparison,  I  must  persist  in  considering  the  value  of  these 
statistics  as  very  slight,  for  the  conclusion  appears  to  me  paradoxical 
that  partial  excision  of  the  tissue  about  the  neoplasm  is  as  effica- 
cious as  ablation  made  as  free  as  possible. 

Recently,  surgeons  have  devised  several  new  methods  of  penetrat- 
ing the  lower  pelvis.  Otto  Zuckerkandl 69  has  proposed  division  of 
the  recto-vaginal  septum,  making  a  transverse  incision  (Fig.  190) 
which  will  comprise  all  the  space  between  the  sciatic  tuberosities, 
instead  of  being  limited  by  the  vaginal  walls.  Frommel 70  has 
adopted  this  procedure  with  success,  and  claims  that  it  allows  the 
surgeon  to  considerably  exceed  the  usual  bounds  of  hysterectomy. 
Sanger,  on  the  contrary,71  who  performed  the  operation  only  on  a 
cadaver,  rejects  it  completely. 

The  para-sacral  or  para-rectal  incision  of  E.  Zuckerkandl72  and 


TREATMENT  OF  CANCER  OF  THE  CERVIX. 


379 


Wolfler 73  furnishes  a  method  of  hysterectomy  for  difficult  cases.  It 
consists  of  a  deep  incision,  either  on  the  left  side  (Zuckerkandl)  or 
upon  the  right  (Wolfler).  The  latter  surgeon  makes  his  incision  from 
a  little  higher  than  the  articulation  of  the  sacrum  with  the  coccyx, 
beginning  from  1  to  2  cm.  outside  of  that  point  and  cutting  downward 
with  a  slight  external  concavity  which  corresponds  to  the  tuberosity 


■  -,  ■-,"'' 


.% 


T-f-W  .    % 


Fig.  190.— Transverse  Perineotomy,  O.  Zuckerkandl.    A,  Anus;  B,  Rectum;  V,  Vagina;  Mra,  Levator 

Ani  muscle ;  Fir,  Ischio-rectal  fossa.  , 

of  the  ischium,  to  a  point  2  to  3  cm.  from  the  fourchette.  In  this  way 
the  ischio-rectal  fossa  is  opened  from  below;  then  a  part  of  the  gluteus 
maximus  is  resected  (Wolfler  then  extirpates  the  coccyx,  which  E. 
Zuckerkandl  preserves),  the  sacro-sciatic  ligaments  and  the  levator  ani 
are  incised,  and  the  rectum  detached  from  the  vagina.  The  culs-de-sac 
of  the  latter  canal  are  then  incised,  and  the  hysterectomy  is  performed 
according  to  the  rules  already  given.     The  operation  is  terminated  by 


380 


CLINICAL   AND   OPEKATIVE   GYNECOLOGY. 


exact  occlusion  of  peritoneum  and  vagina  and  drainage  of  the  para- 
sacral wound,  which  is  partly  closed  by  sutures.  Wolfler  has  employed 
this  method  upon  the  living  subject,  for  extirpation  of  the  rectum 
and  also  the  uterus,  while  E.  Zuckerkandl  has  limited  his  researches 
to  the  cadaver. 

It  seems  to  me  bolder  and  yet  more  rational  to  employ  the  pre- 
liminary operation  devised  by  Kraske  for  reaching  the  cancerous 
rectum  deeply  within  the  pelvis.  It  consists  not  only  in  resection 
of  the  coccyx,  as  Verneuil  and  Kocher  have  done,  but  also  of  the 


Fig.  191. — Hysterectomy  by  the  Sacral  Method. 
Line  of  incision.  (The  dotted  line  shows  the  central 
axis  of  the  body.) 


Fig.  192.- 


-Lines  op  Resection  of  the 
Sacrum. 


lower  wing  of  the  sacrum,  thus  creating  a  very  large  opening  where 
one  can  manoeuvre  with  ease. 

The  patient  is  placed  in  right  lateral  decubitus,  and  starting  from 
the  point  of  the  coccyx  an  incision  is  made  by  the  side  of  that  bone 
for  about  ten  centimetres,  curving  outward  to  end  at  the  middle  of 
the  sacro-iliac  symphysis  (Fig.  191).  The  coccyx  is  cleared  of  the 
periosteum  and  extirpated,  and  at  the  same  time  the  lower  portion 
of  the  sacrum  is  detached  and  removed  with  a  strong  cutting  forceps, 
first  laterally,  and  then,  if  necessary,  by  a  transverse  section.  To 
procure  space  enough  without  injuring  any  important  nervous  branch 
it  is  sufficient  to  carry  this  section  just  below  the  third  sacral  foramen 
(Fig.  192).  The  rectum,  which  it  is  well  to  pack  with  iodoform 
gauze,  is  then  displaced  laterally,  and  the  peritoneum  incised  in 
Douglas'  pouch.     An  enormous  opening  is  thus  produced  (  ig.  193), 


TREATMENT   OF   CANCER  OF   THE   CERVIX. 


381 


through  which  can  be  seen  a  large  portion  of  the  anterior  abdominal 
wall  between  symphysis  and  umbilicus  above  the  bladder.74 

The  first  anatomical  experiments  in  the  application  of  this  method 
of  Kraske's  to  hysterectomy  were  made  by  C.  A.  Herzfeld,  of  Vienna,75 
but  Hochenegg 76  recorded  the  first  operations  upon  the  living  subject. 
One  of  these  was  by  Gersuny,  who  was  thus  able  to  extirpate  a  very 
large  uterus  with  a  cancerous  ganglion  buried  in  the  subperitoneal 
cellular  tissue,  the  other  was  by  Hochenegg  himself,  who  removed 
both  the  uterus  and  a  cyst  of  the  ovary  as  large  as  the  fist,  which  was 
adherent.  Both  cases  recovered,  but  the  second  developed  an  intes- 
tinal fistula. 


Fig.  193. — Hysterectomy  Through  the  Sacrum; 
Opening  Obtained  by  Preliminary  Operation. 


Fig.  194.— Hysterectomy  Through  the  Sacrum; 
Closure  and  Drainage  of'the  Wound. 


A  modification  of  the  preceding  method  was  adopted  almost  at 
once  by  Hegar.77  It  consists  in  making  only  a  temporary  section  of 
the  coccyx  and  lower  portion  of  the  sacrum,  and  laying  them  to  one 
side,  without  complete  extirpation.  When  the  hysterectomy  has 
been  performed,  the  flap  containing  the  bone  is  returned  to  its  place. 
Hegar  had  in  one  case  a  necrosis  of  the  displaced  bone,  and  in  another 
it  remained  movable.  Roux,  of  Lausanne,  followed  Hegar's  example 
for  the  extirpation  of  a  voluminous  cancer  which  could  not  be  re- 
moved through  the  vagina.  In  his  second  case,  as  the  vagina  was  very 
narrow  and  there  were  reasons  to  fear  adhesions  between  it  and  the 
bladder,  Roux  elevated  the  osteo-cutaneous  flap  as  one  opens  a  door, 
by  transverse  section  of  the  sacrum  with  a  cutting  forceps,  and  su- 
tured it  for  the  time  to  the  buttock.  After  ablation'  of  the  uterus  the 
vagina  was  sutured,  the  flap  replaced,  and  the  wound  tamponed  with 
iodoform  gauze  and  closed  at  its  extremities.    Both  patients  recovered. 


382  CLINICAL  AND   OPERATIVE   GYNAECOLOGY. 

Hoclienegg  advises  not  to  proceed  to  detachment  of  the  vaginal 
cnls-de-sac  until  the  peritoneal  wound  has  been  closed  by  sutures ;  in 
this  way  we  avoid  as  completely  as  possible  infection  of  the  serous 
membrane  by  the  tumor.  With  the  same  object,  and  to  render  the 
occlusion  more  complete,  von  Beck  dissects  a  layer  of  peritoneum 
from  the  anterior  face  of  the  uterus. 

Zinsmeister  has  described  a  certain  difficulty  in  finding  the  peri- 
toneal pouch'  at  the  bottom  of  the  wound,  but  this  seems  to  depend 
upon  the  fault,  in  the  operation,  of  not  carrying  the  incision  far  enough 
downward ;  it  should  be  prolonged  almost  to  the  anus. 

The  relations  of  the  rectum  make  it  preferable  to  operate  upon  the 
left  side,  for  then  that  organ  is  more  readily  seen,  and  consequently 
there  is  less  risk  of  injury  if  it  has  been  moderately  filled  with  tam- 
pons. Rectal  wounds,  however,  constitute  one  of  the  dangers  of  the 
operation,  and  require  immediate  suture  {suture  a  Stage).  The  ureter 
may  also  be  cut;  if  that  happens,  it  is  made  to  empty  into  the  rectum 
or  the  vagina.  If  into  the  latter,  its  lower  portion  is  to  be  closed  after 
establishing  free  communication  with  the  bladder.  This  is  better 
than  establishing  a  urinary  fistula  through  the  wound. 

After  having  carefully  sutured  the  base  of  the  wound  itself,  then 
the  peritoneum  (before  extirpation  of  the  uterus),  then  the  vagina, 
(when  the  extirpation  has  been  accomplished),  the  external  wound  is 
partly  closed,  leaving  an  opening  large  enough  to  permit  drainage 
and  antiseptic  tamponing  of  its  cavity— that  is,  of  the  "dead  space" 
which  always  remains.  The  tampons  should  be  left  in  place  from  six 
to  eight  days,  then  renewed  and  gradually  decreased  in  quantity  as 
the  cavity  fills  up.  It  would  be  dangerous  to  make  complete  occlu- 
sion without  some  certain  means  of  issue  for  the  wound  secretions. 

There  is  no  doubt  that  preliminary  resection  of  the  coccyx  and 
sacrum  greatly  facilitates  excision  of  cancer,  which,  without  that, 
could  be  removed  only  through  the  abdomen.  The  facility  of  the 
manoeuvres  of  extirpation  and  hsemostasis  is  also  incomparable.  We 
have  thus  a  valuable  resource  in  cases  where  the  uterus  is  too  volumi- 
nous or  the  vagina  too  narrow  for  the  tumor  to  be  accessible  by  the 
natural  passages,  yet  this  operative  facility  does  not  in  any  respect 
change  the  surgical  limits  which  I  have  thought  it  well  to  assign  to 
hysterectomy.  Whenever  the  cancer  has  extended  beyond  the  limits 
of  the  uterus,  there  should  be  no  attempt  at  total  extirpation. 


TREATMENT  OF  CANCER  OF  THE  CERVIX.  383 


IV.  Cancer  of  the  Cervix,  with  Suspicion  or  Certainty 
of  Deep  Extension. 

When  the  mobility  of  the  uterus  is  lessened,  and  bimanual  palpa- 
tion discloses  a  tumefaction  and  puffiness  at  the  sides  of  the  organ, 
two  hypotheses  are  possible — perimetritis  with  adhesions,  or  exten- 
sion of  the  cancer  to  the  pelvic  cellular  tissue  and  broad  ligaments. 
In  the  first  case  operation  would  be  difficult  and  possibly  danger- 
ous, especially  if  there  were  purulent  foci  as  in  an  unfortunate  case  of 
Le  Bee ; 78  in  the  second  case  it  would  be  both  dangerous  and  useless. 
It  would  be  better  to  refrain  from  interference,  however  great  may  be 
the  resources  offered  by  the  sacral  method. 

The  operative  prognosis  is  doubly  aggravated  in  cancer  with  ex- 
tension. Martin79  had  32$  of  deaths  in  such  cases  instead  of  the 
16.92$  which  he  obtained  in  cancer  limited  to  the  cervix.  The  cases 
which  increase  the  mortality  of  our  statistics  are  very  frequently  of 
this  kind.  Removal  of  the  uterus  from  the  midst  of  a  deep  cancerous 
focus  has  been  improperly  described  under  the  name  of  palliative 
hysterectomy,80  just  as  the  name  of  irregular  supra-vaginal  amputa- 
tion81 has  been  given  to  hysterectomy  undertaken  with  no  proper 
examination,  and  left  incomplete  after  an  exploratory  dissection. 
This  is  an  abuse  of  scientific  language  which  is  much  to  be  regretted, 
for  it  seems  to  justify  the  operation  where  it  is  formally  contra- 
indicated.  An  operation  of  this  kind,  when  it  does  not  kill  the 
patient,  which  is  often  the  case,  is  far  less  palliative  than  simple 
curetting  followed  by  cauterization. 


V.  Cancer  of  the  Cervix  Invading  the  Vagina  Primarily  or 

Consecutively. 

This  invasion  is  an  absolute  contra-indication  to  any  radical  opera- 
tion; for  it  is  either  an  indication  of  the  extension  of  an  advanced 
cancer,  which  has  probably  already  infected  the  lymphatics,  or  it  is 
the  result  of  the  so-called  vaginal  form  of  cancer  of  the  cervix,  for 
which  I  have  proposed  the  name  " timinaire"  and  which  has  an  in- 
vincible tendency  to  extend  to  the  vagina  and  recur  fatally  in  that 
situation.  It  is  then  rationally  the  whole  of  the  vagina  rather  than 
the  whole  of  the  uterus  which  should  be  removed.  Here  the  curette 
and  cauterization  are  the  best  palliatives. 


384  CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 


VI.  Cancer  or  the  Cervix  Extending  to  Vagina  and 
Bladder  or  Rectum. 

In  spite  of  advice  to  the  contrary  from  distinguished  surgeons,82 
to  attempt  a  radical  operation  under  these  conditions,  and  for  this 
purpose  to  remove  the  uterus  and  invaded  portions  of  rectum  or  blad- 
der, seems  to  me  a  fatal  delusion.  The  operation  certainly  is  feasi- 
ble, but  the  recurrence,  or,  better,  the  immediate  local  multiplication, 
is  fatal  after  a  brief  delay,  for  a  cancer  so  far  advanced  ■  has  certainly 
infected  the  lymphatics.  Moreover,  the  gravity  of  hysterectomy  is 
much  increased  in  such  cases,  and  we  may  therefore  demand  whether 
it  is  well  to  expose  the  patient  to  dangers  so  great  for  benefits  so 
precarious. 

In  the  last  three  categories  which  I  have  passed  in  review  I 
have  described  only  a  palliative  operation  capable  of  removing  the 
two  great  causes  of  exhaustion  of  the  patient,  namely,  the  hemorrhage 
and  the  fetid  discharge.  For  this  purpose  it  is  necessary  to  rapidiy 
break  down  and  remove  the  ulcerating  masses  which  cause  these 
symptoms.  The  best  instrument  for  this  is  the  curette,  and  beyond 
all  others  the  cutting  spoon  of  Simon  (Fig.  195).  With  this  instru- 
ment the  largest  mass  of  fungous  growth  may  be  rapidly  removed; 
the  smaller  vegetations  being  followed  into  the  crevices  with 
smaller  sizes  of  the  curette.  The  position  of  the  bladder  and  ureter 
must  be  noted  beforehand  and  the  greatest  caution  observed  in  ex- 
tensive lesions.  If  we  penetrate  into  the  cavity  of  an  invaded  uterus 
we  must,  to  avoid  perforation,  be  careful  to  attack  its  surfaces 
obliquely  and  not  perpendicularly. 

As  soon  as  the  surfaces  have  been  cleaned,  Martin,83  after  freshen- 
ing their  edges,  reunites  them  to  produce  primary  union,  though  it 
seems  to  me  that  the  cases  which  permit  the  application  of  this  ingeni- 
ous method  are  very  rare  and  that  it  is  very  inconvenient.  I  much 
prefer  to  follow  the  curettage  with  the  energetic  application  of  the 
rose  or  olive  shaped  actual  cautery,  by  which  the  neoplastic  processes 
are  followed  up  and  destroyed  in  the  midst  of  the  healthy,  more  re- 
sistant tissue.  This  procedure  is  practically  that  which  has  given 
such  good  results  in  the  hands  of  Koerberle  and  Baker,  and  which 
Schroder  also  recommends ;  I  have  obtained  great  benefit  from  it.84 

This  method  of  treatment  may  be  repeated  at  intervals  of  a  few 
weeks  or  months.     If  we  operate  rapidly,  after  application  of  cocaine 


TREATMENT  OF  CANCER  OF  THE  CERVIX. 


385 


to  the  vagina,  and  under  continuous  cold  irrigation,  anaesthesia  may- 
be omitted,  which  is  desirable,  as  the  patients  are  usually  much  ex- 
hausted and  have  more  or  less  advanced  kidney  lesions.  The  opera- 
tion causes  but  little  pain,  and  only  the  preparation  for  it  is  some- 
what appalling. 

After  the  curettage  a  tampon  of  iodoform  gauze  is  placed  in  the 


Fig.  195.— CtrrrxG  Curettes.    A,  B,  and  C,  cutting  spoons  of  Simon;  D,  Recamier's  cutting  curette;  E, 
Sims'  model;  F,  fenestrated  curette  with  malleable  handle.    G,  Thomas1  serrated  curette. 

cavity  produced  by  the  excision,  and  renewed  at  the  end  of  two  dayTs. 
Injections  of  sublimate  1 : 5,000,  which  appears  to  me  the  best,  may 
also  be  employed.  As  soon  as  the  granulations  at  the  base  of  the 
vagina  begin  to  secrete  with  some  abundance  I  apply  a  small  disc- 
shaped tampon  wet  with  chloride  of  zinc  (1 :  10),  kept  solidly  in  place 
and  isolated  by  a  large  tampon  of  iodoform  gauze  saturated  with 
bicarbonate  of  soda,  the  vagina  being  carefully  tamponed  with  cotton 
so  as  to  avoid  any  displacement.     This  dressing  should  be  renewed 

25 


386  CLINICAL   AND   OPEKATIYE   GYNAECOLOGY. 

every  second  day,  and  each  time  preceded  by  abundant  irrigation 
with  sublimate. 

Chemical  Cauterization.— Various  agents  have  been  employed  for 
this  purpose,  such  as  nitric  or  chromic  acid,  a  1 : 5  alcoholic  solution 
of  bromine,  etc.  The  vagina  must  always  be  protected  by  tampons 
wet  with  a  saturated  solution  of  bicarbonate  of  soda.  Canquoin  paste 
has  its  asdent  defenders,  but  numerous  accidents,  such  as  perf oration, 
peritonitis,  etc.,  due  chiefly  to  the  employment  of  caustic  arrows, 
(fleches)  have  caused  these  to  be  almost  entirely  abandoned ;  chloride  of 
zinc,  however,  managed  with  care,  may  render  real  service.  The  first  to 
aPPly  this  caustic  to  the  treatment  of  cancer  of  the  cervix  were  Mai- 
sonneuve  and  Demarquay.  Marion  Sims,  to  whom  many  authors 
give  the  credit  of  the  procedure,  really  came  after  them,85  and  Van 
de  TVarker  imitated  the  latter  in  his  special  technique  without  cit- 
ing him;86  more  recently,  Frankel87  has  recommended  this  agent 
again.  Its  application  is  as  follows :  The  diseased  surface  is  scraped 
with  the  curette,  and  the  bleeding  stopped  with  the  cautery,  though 
its  action  is  not  carried  very  far.  Then  a  small  tampon  of  cotton  is 
placed  on  the  cervix  after  being  wet  with  a  solution  of  chloride  of 
zinc  (f),  and  this  is  left  in  place  from  twelve  to  twenty-four  hours. 
To  neutralize  the  effects  of  this  acid  caustic  on  the  vagina,  Frankel, 
following  the  example  of  Sims,  superposes  a  tampon  wet  with  bicarbo- 
nate of  soda,  and  anoints  the  vulva  with  vaselin  containing  the  same 
(■$).     The  eschar  is  detached  in  about  ten  days: 

[I  have  seen  very  satisfactory  palliative  results  from  the  chloride 
of  zinc  used  as  follows :  A  sufficient  number  of  very  thin  discs  of  cot- 
ton about  one  inch  in  diameter  are  soaked  in  a  saturated  solution  of 
the  zinc  chloride,  squeezed  flat  and  dried.  A  number  of  larger  tam- 
pons are  prepared  in  the  same  manner  from  a  saturated  soda  solution. 
The  cancerous  growth  is  rapidly  and  vigorously  curetted  until  firm 
tissue  is  reached,  when  hemorrhage,  until  then  profuse,  usually  ceases. 
The  thin  caustic  discs  are  then  carefully  packed  over  the  whole  of  the 
raw  surface  and  the  vagina  carefully  and  firmly  tamponed  with  the 
soda  cotton.  If  the  zinc  cotton  is  used  wet,  it  is  difficult  to  prevent 
the  caustic  from  running  on  to  the  vaginal  walls  and  causing  dis- 
agreeable sloughing.  The  slough  caused  by  this  treatment  is  deep 
and  follows  up  the  diseased  tissue;  it  is  dry  and  leathery  and  usually 
separates  in  from  seven  to  ten  days,  leaving  a  very  clean  granulating 
surface. 

The  first  tampons  are  to  be  removed  on  the  second  day,  and  the 


TREATMENT  OE  CANCER  OF  THE  CERVIX.  387 

parts  dressed  with  iodoform  gauze  until  the  separation  of  the  slough 
is  completed.] 

As  an  injection  for  disinfection  in  cases  of  very  fetid  discharge 
we  may  use  a  solution  of  permanganate  of  potash,  about  10  to  20: 
1,000  (a  solution  which  should  have  a  cherry-red  color)  or  a  dilute 
Labarraque's  solution,  and  besides  employ  the  curette  followed  by  the 
cautery,  or  chloride  of  zinc,  for  destruction  of  the  fungosities. 

Against  the  hemorrhage,  which  will  be  diminished  by  the  fore- 
going measures,  we  may  apply  tampons  wet  with  perchloride  of  iron 
and  then  dried,  after  having  dusted  them  with  iodoform ;  but  the  hot 
iron  energetically  employed  is  the  best  means.  Ergot  is  almost  with- 
out effect,  but  something  may  be  done  with  digitalis. 

Erythema  of  the  vulva  may  usually  be  prevented  by  extreme  per- 
sonal cleanliness,  bathing  with  white  wash  (liq.  plumbi  subacetatis),  and 
inunction  of  borated  vaselin  as  a  protection  from  the  vaginal  discharge. 

Gastric  symptoms  are  to  be  treated  by  tonics  and  bitters,  such 
as  wine  of  quinine,  wine  of  Colombo,  bitter  tincture  (Baume's)  in 
doses  of  two  or  three  drops  before  each  meal,  tincture  of  nux  vomica 
in  ten  or  fifteen  drop  doses  in  the  same  way,  or  amorphous  quassin  in 
pills  of  one  centigram  twice  a  day.  If  the  kidneys  are  affected,  milk 
diet  should  be  ordered.  Against  repeated  vomiting  of  ursemic  origin, 
Winker  has  obtained  good  results  from  tincture  of  iodine  in  drop 
doses  in  water  before  each  meal. 

Constipation  must  be  combated  with  great  care,  for  the  straining 
which  it  causes  is  a  potent  element  in  the  production  of  the  metror- 
rhagia. The  best  means  of  regulating  the  bowels  is  to  give  the 
patient  a  diet  with  plenty  of  vegetables  and  fruit,  green  peas,  prunes, 
etc.  A  large  enema  every  day,  with  the  addition  of  two  tablespoon- 
fuls  of  glycerin,  usually  suffices  so  that  we  avoid  the  constant  and 
injurious  employment  of  purgatives,  but,  if  necessary,  the  following 
may  be  given : 

^  Pulv.  rhei,     .  gr.  viiss. 

Pulv.  belladonnse, gr.  i. 

M.  ft.  caps.  No.  1. 

If  these  measures  are  not  successful,  we  must  have  recourse  to 
drastic  purgatives,  of  which  the  best  is  podophyllin : 

fy  Podophyllin, gr.  ss. 


Ext.  belladonna, gr. 

M.  ft.  pil.  No.  1. 


i 


388  CLINICAL   AND   OPERATIVE-  GYNAECOLOGY. 

The  pains  are  seldom  benefited  by  surgical  interference,  but  fre- 
quent injections  and  dressings  diminish  them  sensibly.  Morphine  by 
hypodermic  injection  could  hardly  be  refused  without  cruelty  to 
patients  whose  condition  is  hopeless.  It  is  only  necessary  to  enforce 
the  limits  within  which  it  may  be  employed,  and  so  avoid  such  abuse 
of  the  drug  as  would  alter  the  digestive  function  and  depress  the 
bodily  powers.    ' 

[In  many  cases  the  most  satisfactory  results  in  relieving  pain  are 
obtained  by  the  employment  of — 

5  Phenacetine, 3 i- 3 iss. 

Codeinge, gr.  vi.-gr.  xij. 

M.  ft.  chart,  (vel  caps.)  ~No.  vi. 

Sig.  One  powder  to  be  taken  three  times  a  day  for  pain.] 

A  tonic  regimen  should  also  be  prescribed. 

The  following  have  been  recommended  as  specifics:  Hemlock, 
which  merely  aggravates  the  stomach  disturbance;  condurango  in 
decoction  (15  gm.  to  200  gm.  water),  which  acts  only  as  a  stomachic; 
and  Chian  turpentine  (0.5  to  1.0  gm.  in  pill),  which  seems  to  have  no 
injurious  action,  although  its  therapeutic  value  has  not  been  demon- 
strated. [Methylene  blue  (pyoktanin),  in  two  cases  in  which  I  have 
employed  it  locally,  seemed  to  lessen  the  amount  of  hemorrhage,  pain, 
and  fetor,  but  had  no  perceptible  effect  in  checking  the  progress  of 
the  disease.] 

TIL — Cancer  of  the  Cervix  Complicating  Pregnancy. 

It  is  impossible  to  recognize  a  pregnancy,  in  a  woman  with  cancer 
of  the  cervix,  before  the  fourth  month,  for  the  volume  of  the  uterus 
may  be  legitimately  attributed  to  the  presence  of  the  neoplasm.  If, 
however,  the  diagnosis  should  be  made  at  that  early  period,  ought 
the  fact  to  modify  the  treatment  ?  I  think  not.  What  we  know  of 
the  accelerating  influence  of  pregnancy  on  uterine  cancer  on  the  one 
hand,  and  the  great  probability  of  abortion  on  the  other,  make  va- 
ginal hysterectomy  perfectly  legitimate  whenever  it  is  applicable  to 
the  gravid  uterus.  For  this  operation  the  disease  must  be  limited, 
and  the  volume  of  the  uterus  must  permit  extraction  by  the  vagina. 
It  is  then  remarkably  easy  on  account  of  the  laxity  of  the  tissues,88 
and  is  infinitely  preferable  to  intra-  or  supra-vaginal  amputation  of 
the  cervix,  which  is  a  frequent  cause  of  abortion  and  has  often  been 
followed  by  rapid  recurrence.89     [The  primary  mortality  seems  to  be 


TREATMENT  OF   CANCER  OF  THE  CEUVIX.  389 

even  lessened  by  the  presence  of  early  pregnancy;  fourteen  cases, 
all  successful,  where  the  cancerous  uterus  with  a  pregnancy  advanced 
from  two  to  four  months,  has  been  removed  by  vaginal  hysterectomy 
having  already  been  recorded.97] 

If  the  neoplasm  has  extended  to  the  adjacent  tissues  we  must  dis- 
tinguish between  the  very  hard  cervix,  when  abortion  should  be  in- 
duced and  followed  by  palliative  treatment  of  the  cancer  (curette  and 
cauterization),  and  the  fungous  cervix,  all  of  whose  circumference  is 
not  invaded,  when  it  is  best  to  wait  and  not  induce  abortion  until 
feebleness  of  the  foetal  heart  renders  it  probable  that  its  death  is 
imminent. 

When  the  labor  is  difficult,  we  should  employ,  according  to  cir- 
cumstances, version  or  the  forceps,  and  as  a  final  resource  the  Ca3sa- 
rean  operation,  for  it  seems  to  me  that  we  should  not  sacrifice  by 
craniotomy  the  living  child  of  a  mother  who  is  beyond  hope.90 

Finally  we  must  consider  the  rare  cases  where  the  cancer  is  still 
limited,  but  the  uterus  is  too  far  developed  for  extraction  by  the 
vagina  without  evacuation  of  its  contents.  It  is  impossible  to  give 
rules  which  shall  apply  to  all  cases ;  the  study  of  each  patient  must 
be  the  surgeon's  guide.  The  following  operations  may  be  adoj)ted, 
according  to  the  special  conditions  of  each  case: 

A.  Induced  labor,  with  hysterectomy  after  a  few  days.91 

B.  Cesarean  operation,  with  colpo-hysterectomy  later.92 

Q.  Total  extirpation  of  the  gravid  uterus,  with  dissection  of  the 
vagina,  by  laparatomy,  according  to  the  procedure  adopted  for  the 
first  time  with  full  success  by  Spencer  Wells  on  October  21st,  1881. 93 

D.  Hysterectomy  by  the  sacral  method,  after  resection  of  the 
coccyx  and  a  part  of  the  sacrum  if  necessary. 

VIII.  Cancer  of  the  Cervix  Complicating  Fibroma. 

If  the  fibrous  tumor  is  larsre  enough  to  form  an  absolute  ol  >stacle 
to  the  accomplishment  of  vaginal  hysterectomy,  there  is  only  the 
choice  between  the  abdominal  operation  of  Freund,  extirpation, 
through  the  pelvis  (sacral),  and  curetting  followed  by  cauterization. 
One  or  the  other  of  these  last  two  is  the  method  which  I  should 
adopt,  for  the  dangers  of  abdominal  hysterectomy  are  very  serious 
in  such  cases.  If,  on  the  other  hand,  the  fibroma  is  of  small  size,  we 
may  perform  vaginal  hysterectomy.  I  have  done  this  without  very 
great  difficulty94  in  one  case  where  there  was  a  subrjeritoneal  fibroma 
of  the  size  of  the  fist. 


390  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

IX.  Cancer  of  the  Cervix,  with  Complicating  Cyst  of  the 

Ovary. 

Should  hysterectomy  be  performed,  if  it  is  legitimate,  before  the 
ovariotomy  or  after  it,  or  both  in  one  session?  I  consider  that  the 
affection  whose  course  is  the  more  menacing  should  be  first  treated, 
namely,  the  cancer.  If  the  radical  operation  is  justifiable,  we  should 
first  perforin  total  extirpation  by  the  vagina  and  after  recovery  pro- 
ceed to  the  ovariotomy;  if,  on  the  contrary,  palliative  treatment  of 
the  cancer  alone  is  possible  on  account  of  its  extension,  we  should 
not  attempt  ovariotomy  as  the  patient  will  survive  but  a  very  short 
time.  Asch 95  records  a  case  where  he  performed  total  extirpation  of 
the  cancerous  uterus  and  ovariotomy  at  the  same  time.  The  uterus 
was  first  removed  by  the  vagina,  then  the  cyst  by  laparatomy.  In 
beginning  the  second  operation,  bubbles  of  air  were  noticed  in  the 
peritoneum,  evidently  introduced  by  the  vaginal  opening.  On  the 
eighth  day,  after  removal  of  the  sutures,  there  was  gaping  of  the 
wound,  and  escape  of  the  intestines,  which  displaced  the  bandage  and 
rested  on  the  thighs  for  two  hours.  These  loops  of  intestine  were 
cleansed  with  carbolic  compresses  and  returned  to  the  abdomen  and 
a  second  suture  made.  The  patient  recovered.  It  is  difficult  to  think 
that  this  serious  accident  could  have  occurred  if  the  operation  had 
been  performed  in  two  sessions. 

I  have  observed  one  curious  case  of  suppuration  and  cure  by  spon- 
taneous evacuation  of  an  ovarian  cyst  after  colpo-hysterectomy.  I 
had  resolved  to  follow  my  first  operation  by  ovariotomy,  when,  with- 
out great  increase  in  temperature,  there  was  a  purulent  discharge 
from  the  vagina  on  the  fifteenth  day,  the  cystic  tumor  disappeared, 
and  soon  after  the  patient  made  a  complete  recovery.96 

BIBLIOGRAPHY. 

1.  Schroder:  Mai.  des  Org.  G6n.  de  la  fern.,  French  ed.,  1886,  page  314. 

2.  Pawlik:  Wien.  Med.  Clin.,  Dec,  1882. 

3.  Barraud:   Hyst6rectomie  Vaginale.     Paris  Thesis,  1889,  pp.  63  and  83. 

4.  This  opinion  which  I  advocated  in  1888,  now  finds  a  growing  number  of 
partisans.  See  Landau:  Samml.  klin.  Vortr.,  No.  338,  and  Ott :  Ann.  de  Gyn6c, 
October,  1889,  page  26. 

5.  Verneuil  :  Arch.  Gen.  de  M<5d.,  January,  1884. 

6.  Koeberl6:  Trait,  des  Cancers,  etc.'    Gaz.  Hebd.,  February  26th,  1886. 

7.  W.  H.  Baker:  Amer.  Jour.  Obstet.,  1882,  p.  265,  and  1886,  p.  184. 

8.  E.  Van  de  Warker  :  Amer.  Jour.  Obst.,  1884,  p.  225. 

9.  Schroder :  Zeit.  f.  Geb.  und  Gyn.,  hi.,  p.  419,  and  vi.,  p.  213. 


TREATMENT  OF  CANCER  OF  THE  CERVIX.  391 

10.  Hofmeier  :  Berliner  klin.  Woch.,  Nos.  6  and  7,  1886.  As  to  final  results  :  in 
7  eases  there  was  no  information;  43  had  a  return  of  the  disease  within  a  year,  45 
had  none;  among  83  followed  more  than  two  years.  8  died.  7  were  lost  to  view,  and 
among  37  there  were  31  cures,  or  46  per  cent. ;  of  49  after  three  years,  4  died,  6  lost 
to  view,  26  with  a  recurrence,  23  cured,  or  47  per  cent. 

11.  Gusserow  :  Die  Neubild.  d.  Uter.     Eight  deaths  in  33  cases,  or  9  per  cent. 

12.  W.  H.  Baker:  Ainer.  Jour.  Obstet.,  1882,  p.  265.  and  1886,  p.  484,  reports  10 
cases  without  a  death,  2  recurred  after  a  few  months,  1  cure  after  two  years  and 
then  return,  1  cure  of  four  years.  1  of  four  years  and  seven  months.  1  of  five  years, 
1  of  five  years  and  three  months,  2  of  six  years,  and  1  of  eight  years  and  then  return. 
Reamy:  Amer.  Jour.  Obst.,  1888,  p.  1,028,  57  high  amputations,  with  2  deaths  from 
operation;  return  in  29  from  one  to  fourteen  years;  26  remained  cured  from  one  to 
fifteen  years. 

13.  Wells  :  British  Med.  Jour..  December,  1888;  1  death  in  6  cases.  Wallace, 
same  journal,  September  15th,  1883;  10  cases.  2  deaths.  20  per  cent. 

14.  Kceberl6:  Gaz.  Hebd.,  February  26th,  1886.  He  prefers  high  excision  of 
the  cervix,  with  energetic  cauterization,  to  total  hysterectomy. 

15.  Marchand:  Bull,  de  la  Soe.  de  Chir.,  Oct.,  1888;  6  cases.  1  death,  peritonitis. 

16.  Buffet:  Graz.  des  Hop.,  1886,  cited  by  Barraud:  2  cases.  2  immediate  suc- 
cesses. 

17.  T(?denat,  cited  by  Barraud.  loc.  cit.  (3),  p.  74;  1  case,  1  cure.  Combining  the 
the  results  of  these  three  surgeons  we  obtain:  9  cases,  1  death  from  operation,  or 
11.11  per  cent;  2  lost  to  view,  2  with  early  return.  2  deaths  at  the  end  of  11  and 
30  months,  2  cures  after  3  and  4  years. 

18.  Barraud:  Loc.  cit.  (3),  p.  48,  obtains  the  figure  5.88  per  cent  from  a  small 
series  of  34  cases  in  1888  operations  of  Pean,  Bouilly,  Terrier,  an  1  Richelot. 

19.  Munchmeyer:  Cent.  f.  Gym,  1889,  No.  31:  in  160  vaginal  hysterectomies  for 
different  diseases  between  1883  and  1889,  Leopold  had  a  mortality  of  only  5.4  per 
cent. 

20.  Dmitri  de  Ott :   Annal.  de  Gym,  Oct.  and  Nov.,  1889. 

21.  C.  Fenger:  Am.  Jour.  Obst.,  Jan.,  1889,  p.  90. 

22.  Huge:  Cent.  f.  Gym,  1885,  p.  376.  Strosch:  Ibid.,  1888,  No.  50.  Fritsch: 
Arch.  f.  Gym,  1887,  Bd.  ii.,  Hft.  3,  p.  362.  Terrier:  Rev.  de  Chir.,  May,  1888.  Abel: 
Berl.  klin." Woch.,  1889,  No.  30. 

23.  For  history  see  Rochard:  Histoire  dela  Chirurgie  Franc,  au  xix.  Siecle.  pp. 
265-267.  C.  G.  Hesse:  Memoire  pour  Servir  a  FHist.  de  TExtirp.  de  l'Uter.,  Rev. 
Medic,  1827,  vol.  2,  p.  07.  Velpeau:  Nouveaux  Elements  de  Med.  Operat.  Paris, 
1839,  t.  iv.,  p.  426.     Gomet:   Lliysterec.  Yagin.  en  France.  Paris  Thesis,  1886. 

24.  Among  the  predecessors  of  the  surgeons  of  to-day  it  is  just  to  cite  Sauter  of 
Constance,  who  performed  the  first  vaginal  extirpation  of  the  non-prolapsed  can- 
cerous uterus  in  1822  with  one  successful  case:  andReeamier.  who  in  1829  obtained 
a  cure  in  his  first  operation.  After  these  came  multiplied  reverses  and  the  opera- 
tion was  abandoned  until  the  era  of  antiseptic  surgery.  For  the  beginnings  of 
this  renaissance  see  Freund:  Zur  Totalextirpation  des  Uterus.  Zeit.  f.  Geb.  und 
Gym,  vi.,  2.  Czerny:  Ueber  Ausrottung  des  Gebarmutterkrebs,  Wien.  med. 
Wochem,  1879,  Nos.  45,  49.  Demons:  Arch.  General,  de  Me"d.,  1883,  t.  ii.,  p.  257.  J. 
Boeckel:  Bull,  de  la  Soc.  de  Chir.,  June,  1884. 

25.  A.  Martin:  Path,  und  Ther.  der  Frauenk.,  p.  368. 

26.  Krukenberg  has  published  a  case  of  death  on  the  7th  day  from  torsion  of  a 
loop  of  intestines  about  a  drain  which  penetrated  the  peritoneal  cavity.  Nieder- 
rhein.  Gesell.  in  Bonn,  Cent.  f.  Gym,  1887.  37. 

27.  Hegar  and  Kaltenbaeh  :  Die  operat.  Gym.  3d  edit.,  1886.  p.  446. 

28.  In  a  case  of  W.  Duncan"s  where  the  ovaries  were  not  removed,  there  were 


392  CLINICAL  AND   OPERATIVE   GYNECOLOGY. 

three  attacks  of  very  severe  pain  corresponding  exactly  to  the  menstrual  epochs, 
an  indubitable  sign  of  ovulation  and  circumscribed  peritonitis;  in  view  of  their 
final  cessation  the  author  supposed  that  cirrhosis  of  the  ovaries  had  occurred.  The 
same  accident  was  observed  in  a  case  of  W.  MacCormac's,  cited  by  Duncan,  Trans. 
London  Obst.  Soc,  vol.  xxvii.,  p.  29.  SchrOder  has  also  noticed  pain  at  such  times 
in  certain  rare  cases. 

29.  Grammatikati:   Cent.  f.  Gyn.,  1889,  No;  7.     Grlaevecke:  Arch.  f.  Gyn.,  Bd. 
xxxv.,  Hft.  1. 

30.  Fritsch:   Cent,  fur  Gyn.,  1883,  No.  37. 

31.  Olshausen:   Clin.  Beitrag.  z.  Geb.  u.  Gyn.,  1885. 

32.  Schatz:  Arch.  f.  Gyn.,  xxi.,  Hft.  3.     Uterus. 

33.  Brennecke:  Zur  Tech.  d.  vag.  Extirp.     Cent.  f.  Gyn.,  1883,  p.  763. 

34.  P.  Mvlller:  Ueber  die  Extirp.  Uter.  vag.  Deutseh.  med.  Woch.,  1881,  Nos. 
10  and  11.     Cent.  f.  Gyn.,  1882,  No.  8.    . 

35.  Hegar  and  Kaltenbach:   Operat.  Gyn.,  3d  edit.,  p.  445. 

36.  C.  H.  Jennings:  On  Excision  of  the  Entire  Uterus  for  Cancer;  Lecture  at 
the  Cancer  Hospital,  March  5th  and  12th,  1886;  Lancet,  Nos.  15  and  16. 

37.  The  first  idea  of  applying  long  forceps  as  a  procedure  of  choice  and  leaving 
them  in  position  for  two  or  three  days,  belongs  to  Spencer  Wells  (Ovar.  and  Uter. 
Tumors,  London,  1882,  p.  526)  who  described  it  in  1882.  His  pupil,  Jennings,  finding 
some  difficulties,  simplified  his  master's  rules,  which  have  been  recently  discussed 
anew  by  Duncan,  Jan.,  1885,  before  the  Obstet.  Soc.  of  London,  who  (Oct.  30th, 
1885)  applied  the  long  forceps  of  Wells  and  allowed  them  to  remain;  cure;  case 
published  March,  1886.     In  Nov.,  1885,  Richelot,  Bull,  de  la  Soc.  de  Chir.,  Nov., 

1885,  renewed  before  the  Soc.  de  Chir.  of  Paris  the  theoretic  proposal  of  Wells,  and 
•on  April  28th,  1886,  put  his  plan  into  execution,  Commun.  de  l'Acad.  de  M6d.,  July 

13th,  1886,  Union  M6d.,  July,  1886.  Pean,  who  claimed  priority  in  this  practice 
and  who  was  probably  the  first  to  use  it  in  view  of  his  great  extension  of  the 
application  of  forceps  to  vessels,  did  not  publish  till  1886  in  thesis  by  Gomet, 
De  l'Hysterec.  vag.  en  France,  Paris  Thesis.     Buffet,  of  Elbueuf,  Gaz.  des  Hopit., 

1886,  No.  116,  reports  a  case  on  June  19th,  1885,  where  Pean  employed  forcipressure 
as  a  necessity  in  a  hysterectomy  for  myxo-sarcoma.  The  original  point  of 
Richelot's  procedure  is  the  systematic  use  of  the  forceps  even  when  the  applica- 
tion of  a  ligature  is  easy.  On  the  priority  of  the  use  of  forceps  for  the  broad 
ligaments  as  questioned  between  Pean  and  Richelot,  see  Pean,  Compt.  rend,  du 
Cong.  Franc,  de  Chir.,  1886,  p.  388.  Richelot:  Nouv.  Arch.  d'Obst.  et  de  Gyn., 
Oct.  25th,  1889,  p.  449. 

38.  R.  de  Madec:  Trait,  chir.  du  Cancer  del'Uter.,  Paris  Thesis,  1887.  Doleris: 
Nouv.  Pinces  pour  les  Lig.  larges;  Bull,  de  la  Soc.  de  Chir.,  March,  1887.  Polk: 
Trans,  of  Obst.  Soc.  New  York,  Am.  Jour.  Obst.,  March,  1888,  p.  302. 

39.  For  the  criticisms  of  this  procedure  see  Demons:  Cong.  Franc,  de  Chir.; 
Compt.  rend.,  3me  session,  1888.  S.  Pozzi:  Ibid,  and  Indie,  et  Techn.  de  l'Hysterec. 
vag.  pour  Cancer.     Annal.  de  Gyn.,  Aug.,  1888. 

40.  Richelot:  Bull.  Soc.  Chir.,  Dec.  29th,  1886,  pp.  946  and  952. 

41.  Pawlik:   Cent.  f.  Gyn.,  1890,  No.  1,  p.  22. 

42.  Lane:   San  Francisco  Pacific  Med.  and  Surg.  Jour.,  April,  1880. 

43.  Frank:   Ueber  extra-perit.  Uterusextirp.   Arch.  f.  Gyn.,  Bd.  xxx.,  p.  1. 

44.  J.  Boeckel:  Bull.  Soc.  Chir.  June,  1884.  Richelot,  cited  by  de  Madec,  loc. 
cit.,  p.  80.     Lannelongue,  cited  by  Demons,  Cong.  Fr.  de  CKir.,  1888. 

45.  Certain  authors,  among  whom  are  J.  Boeckel,  have  treated  a  fistula  after 
hysterectomy  involving  the  ureter  by  nephrectomy;  one  could  also,  as  Kalten- 
bach prefers,  establish  a  free  communication  between  the  vagina  and  the  bladder 
and  then  close  the  lower  part  of  the  vagina  by  the  operation  called  kolpokleisis. 


TREATMENT  OF  CANCER  OF  THE  CERVIX.  393 

46.  Duplouy,  of  Rochefort:  Cong.  Franc,  de  Chir.,  1880.  Ktister,  cited  in  Union 
MeU,  March,  1886.  Vrobleski :  Union  MeU,  October  18th,  1888.  A  case  of  hys- 
terectomy for  a  non-cancerous  uterus. 

47.  P.  Brunner  :  Ueber  Extirp.  des  Uter.  von  der  Scheide.     Zurich  Thesis,  1884. 

48.  Munde"  :  Gyn.  Trans.,  1884,  vol.  ix. 

49.  W.  A.  Duncan  :   Loc.  cit.  (28). 

50.  M.  Hache:  Rev.  des  Sciences  MSdic,  1887,  p.  721. 

51.  Sara  Post:   Kolpohysterec  for  Cancer.     Am.  Jour.  Med.  Sci.,  1886,  p.  113. 

52.  A.  Martin:  Trans.  Internat.  Med.  Cong.,  Sept.,  1887.  Amer.  Jour.  Obst., 
Oct.,  1887,  p.  1,108. 

53.  Leopold,  cited  by  Munchmeyer:  Ueber  die  Endergeb.,  etc.  Arch.  f.  Gyn., 
Bd.  xxxvi.,  Heft  No.  31. 

54.  Kaltenbach:  Berl.  klin.  Woch.,  1889,  Nos.  18  and  19. 

55.  D.  de  Ott:  Loc.  cit.  (20). 

56.  Pean,  cited  by  Secheyron:   Trait.  d'Hyst<5r.,  1889,  p.  542. 

57.  S.  Pozzi:  Indicat.  et  Tech.  de  l'Hyst.  Vag.  pour  Cancer.  Ann.  de  Gyn., 
August,  Sept.,  1888. 

58.  M.  Barraud:   Loc.  cit.  (3),  p.  6. 

59.  Richelot:   Union  MSdic,  April  3d,  1888. 

60.  Bouilly,  cited  by  Hache:   Loc.  cit.  (50). 

61.  Hache:  Loc.  cit.  (50),  page  127. 

62.  S.  Pozzi:  Ann.  de  Gyn.,  Sept.,  1888,  p.  192. 

63.  Munchmeyer:   Arch,  fur  Gyn.,  Bd.  xxxviii.,  Heft  3,  1889. 

64.  D.  de  Ott  remarks  that  from  the  point  of  view  of  survival  it  is  necessary  to 
divide  the  patients  into  two  categories;  those  operated  upon  at  the  first  of  the  dis- 
ease, and  those  where  the  lesion  is  already  far  advanced.  The  first  alone  gives  a 
survival  of  more  than  one  year,  and  among  these  cases  there  has  been  one  cure  main- 
tained for  three  and  a  half  years  and  another  for  two  years  and  one  month.  On 
the  contrary,  all  patients  operated  upon  too  late  are  exposed  to  a  return  of  the 
tumor  in  from  one  to  eleven  months. 

65.  S.  Pozzi:   Bull.  Soc.  Chir.,  1888,  p.  771. 

66.  Hofmeier:  Zeit.  f.  Geb.  und  Gyn.,  Bd.  xiii.,  Hft.  2,  1886.  This  work  is  not 
to  be  confounded  with  others  by  the  same  author  upon  this  subject,  which  are  less 
complete.  Centr.  f.  Gyn.,  1884,  p.  284,  and  ibid.,  1886,  page  92,  and  Berliner  klin. 
AVoch.,  1886,  Nos.  6  and  7.  The  greatest  differences  exist  between  the  statistics  of 
these  various  publications,  which  has  caused  some  confusion  in  citations  made 
from  them. 

67.  Verneuil:   Bull.  Soc.  Chir.,  October,  1888. 

68.  Martin:  Path,  und  Ther.  der  Frauenk.,  2d  ed.,  p.  309. 

69.  O.  Zuckerkandl:  Wien.  mecl.  Woch.,  1888,  Nos.  11  and  16;  1889,  Nos.  12, 
14,  15,  16,  18,  and  Wien.  med.  Presse,  1889,  No.  7. 

70.  Frommel  (Erlangen) :  Third  Cong,  of  German  Gynak.,  Freiburg,  1889.  Cent, 
f.  Gyn.,  1889,  No.  31. 

71.  Sanger  :   Cent.  f.  Gyn.,  1889,  No.  31. 

72.  Zuckerkandl :  Notizen  fiber  die  Blosslegung  der  Beckenorgane.  Wiener 
klin.  Woch.,  1880,  No.  14. 

73.  WOlfler  :  Ueber  den  Para-sacralen  und  Para-rectalen  Schnitt,  etc.  Wiener 
klin.  Woch.,  1889,  No.  15. 

74.  Kraske :  Verhandl.  XIV.  Cong.  Deutsch.  Gesell.  f.  Chir.,  1885.  G.  Hoch- 
enegg:  Die  Sacrale  Methode,  etc.  Arbeit,  und  Jahresb.  der  S.  Chir.  Univ.  Klin, 
zu  Wien,  1888,  p.  13.  Roux  :  De  l'Acces  des  Org.  Pelv.  par  la  Voie  Sacr£e.  Rev. 
M<3d.  de  la  Suisse  Romande,  1889. 

75.  C.  A.  Herzfeld  :   Allg.  Wien.  med.  Zeitschrift,  1888,  No.  34. 


394  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

76.  J.  Hochenegg:  Die  Sakr.  Operat.  in  der  Gyn.  Wiener  klin.  Woch.,  1889, 
No.  9.  He  had  already  suggested  that  the  preliminary  operation  of  Kraske  could 
be  applied  to  extirpation  of  the  uterus  and  its  adnexa  in  a  memoir  relative  to  ex- 
tirpation of  the  rectum,  published  a  little  before  Herzfeld's  article.  Wiener  med. 
Woeh.,  August,  1888,  No.  19. 

77.  Hegar:  Berlin,  klin.  Woch.,  1889,  No.  10.  Wiedow  :  Centr.  f.  Gyn.,  1889, 
No.  29.  B.  von  Beck  :  Die  Osteopl.  Resec.  des  Kreuz.,  etc.  Zeit.  f.  Geb.  und  Gyn., 
Bd.  xviii.,  Heft  1,  1890,  and  Centr.  fur  Gyn.,  1890,  p.  50.  In  four  cases  reported  by 
von  Beck  there  were  two  deaths,  and  two  cures  with  rapid  consolidation  of  the 
sacrum.  Zinsmeister,  ibidem,  reports  one  case  where  there  was  a  wound  of  the 
rectum  and  death  in  four  hours.  Hegar  performed  his  first  hysterectomy  by  the 
pelvic  method  in  November,  1888,  while  Gersuny  did  his  in  December;  but  the 
latter  was  published  first. 

78.  LeBec:  Hyster.  Vag.,  double  Pyosal.,  etc.     Gaz.  des  H6p.,  1888. 

79.  Martin:  Zur  Statis.  der  Totalextirp.  bei  Carcin.  Berlin,  klin.  Woch.,  No. 
5,  1887. 

80.  Richelot,  cited  by  De  Madec  :  Trait.  Chirurg.  du  Cancer  de  TUter.  Paris 
Thesis,  1887,  p.  90. 

81.  Richelot :  Union  MM.,  1888,  p.  111.  See  my  criticisms  on  this  subject,  Ann. 
de  Gyn.,  August,  1888,  vol.  xxx.,  p.  92. 

82.  Mikulicz,  cited  by  Schwartz  :  Rev.  de  Chir.,  1882,  expresses  himself  thus 
upon  the  point  :  "As  long  as  one  regarded  the  bladder  and  the  rectum  as  a  noli 
me  tangere,  just  so  long  did  extirpation  of  the  uterus  fail  of  desirable  results;  there 
must  be  no  fear  in  attacking  both  rectum  and  bladder  freely,  for  they  are  not 
organs  essential  to  life."  Terrier,  cited  by  Gomet :  Paris  Thesis,  1886,  is  evidently 
inspired  by  these  words  when  he  says,  "We  should  not  hesitate  to  operate,  since 
extirpation  of  a  part  of  the  rectum  or  of  the  bladder,  which  may  be  invaded,  will 
not  be  incompatible  with  existence." 

83.  Martin  :  Path,  und  Ther.  der  Frauenk.,  pp.  99  and  100,  and  von  Rabenau  : 
Berlin,  klin.  Woch.,  1883,  No.  13. 

84.  Kceberle":  Gaz.  Hebd.,  February  26th,  1886.  W.  H.  Baker  :  Amer.  Journal 
Obstet.,  1882,  p.  265,  and  1886,  p.  184.  Schroder:  Loc.  cit.  (1),  p.  325.  Despreaux  :  Du 
Curet.  Uterin.  Paris  Thesis,  1887.  A.  Pozzi :  Le  Traitement  du  Cancer  de  l'Uter. 
Paris  Thesis,  1888. 

85.  Marion  Sims  :   Amer.  Jour.  Obstet.,  vol.  xii.,  1879. 

86.  Van  de  Warker  :  Ibid.,  vol.  xvii.,  1884. 

87.  Frankel :  Centr.  f.  Gyn.,  September,  1888,  No.  37.  See  on  this  subject  a 
discussion  at  the  Berlin  Soc.  of  Gyn.,  June  22d,  1888.  Martin  on  this  occasion  con- 
demned caustics  from  their  blind  and  dangerous  action. 

88.  Hofmeier:  Presentation  to  the  Berlin  Gyn.  Soc.  of  a  gravid  uterus  in  the 
second  month,  etc.     Centr.  f.  Gyn.,  1887,  No.  13. 

89.  Hofmeier  :  Ueber  Operat.  am  Schwang.  Uter.  Deutsche  med.  Woch.,  1887, 
No.  19. 

90.  Consult  on  this  special  point,  Barbulee:  De  la  Conduite  a  Tenir  dans  le 
Cane,  du  Col  de  FUttSr.  pendant  la  Gross.,  etc.  Paris  Thesis,  1884.  Bar:  Du  Cane, 
uter.  pendant  la  Gross.,  etc.,  Paris  Thesis,  1886.  Gusserow  :  Die  Neubildung.  des 
Uterus,1885,  p.  251.  Herman  :  Cane,  of  the  Uter.  Complic.  Preg.  London  Obstet. 
Trans.,  vol.  xx.,  p.  206.  Hanks  :  Preg.  Complic.  by  Uter.  Tumors.  Amer.  Jour. 
Obst.,  March,  1888. 

91.  Berthod:  Gaz.  des  Hop.,  1886,  No.  46.  Report  of  a  case  of  Bouilly's  followed 
by  success  for  the  mother;  pregnancy  at  the  sixth  month. 

92.  Teuffel  :  Ein  Fall  von  Kaiserschnitt,  etc.  Arch.  f.  Gyn.,  Bd.  xxxvi.,  Heft 
2,  1889.     Extraction  of  a  living  child  by  Cesarean  section;  death  of  the  mother  after 


TREATMENT  OF  CANCER  OF  THE  CERVIX.  395 

21  days  from  septic  infection.  Teuffel  recommends  that  the  operation  be  followed 
by  the  use  of  a  large  drain  through  the  cervix  when  it  is  obstructed  by  the  neo- 
plasm, to  avoid  sepsis.  Merkel:  Mtinchener  med.  Woch.,  May  21st,  1889,  also  ob- 
tained a  living  infant,  but  the  mother  died  on  the  seventh  day. 

93.  Spencer  Wells:   Ovarian  and  Uterine  Tumors,  London,  1882,  p.  518. 

94.  Bourges:   Gaz.  M6d.  de  Paris,  July  7th, 

95.  Asch:   Cent,  fur  Gyn.,  1887,  No.  27. 

96.  S.  Pozzi:   Ann.  de  Gyn.,  Sept.,  1888. 

97.  MundtS  and  Wells  :   Sajou's  Annual,  1891. 


OHAPTEE  XVI. 

CANCER  OF  THE  BODY  OF  THE  UTERUS. 

Adenoma  of  the  Uterus. — 'There  is,  except  among  French  authors,  a 
certain  amount  of  confusion  regarding  adenoma  of  the  uterus.  Some 
authors  apply  the  name  of  typical  or  benign  adenoma  to  what  I  have 
described  as  glandular  endometritis  in  a  preceding  chapter,  while 
atypical  or  malignant  adenoma  is   the  same  as  the  first  stages  of 


Fig.  196.— Benign  Adenoma  of  the  Uterine  Mucous  Membrane.  '  (Compare  with  Fig.  100,  Glandular  Endo- 
metritis), Wyder. 

degeneration  of  the  mucous  membrane  in  epithelioma.  This  differ- 
ence they  derive  from  the  anatomical  conditions  entirely,  depending 
upon  the  distinctions  and  refinements  of  histology,  while  I,  with  all 
other  French  authorities,  have  adopted  the  nosology  to  the  clinical 
aspect.    The  conception  of  adenoma  plays  no  part  at  the  bedside 


CANCER  of  the  body  of  the  uterus.  397 

of  the  patient.  I  refer  to  the  chapter  on  Metritis  for  whatever  con- 
cerns benign  adenoma,  having  described  its  pathology  with  glandular 
metritis  and  its  symptoms  with  catarrhal  and  hemorrhagic  metrititis 
and  mucous  polypi. 

Malignant  adenoma  is  then  only  the  initial  stage  of  cancer  of  the 
mucous  membrane.  If  there  is  any  need  of  further  distinction  it  may 
be  described  histologically  as  glandular  epithelioma,  adeno-carcinoma, 
or  glandular  carcinoma.1 

It  suffices  to  glance  at  the  two  following  figures  to  see  the  enor- 
mous difference  which  separates  these  conditions,  and  to  grasp  at  the 
same  time  the  transitions  which  permit  the  transformation  of  the  one 
into  the  other ;  for  a  lesion  begun  as  a  slight  glandular  endometritis 
may  become,  if  inveterate,  a  glandular  endometritis  of  the  most  pro- 
nounced type  (typical  benign  adenoma),  may  then  degenerate  into  an 
atypical  malignant  adenoma,  and  this  is  the  first  stage  of  cancer.2 

In  the  case  of  the  so-called  benign  adenoma  (Fig.  196)  the  prolif  era- 
tion  is  absolutely  typical,  there  are  no  solid  epithelial  tubes,  and  the 
cylindrical  epithelium  is  in  one  layer  only.  Between  the  glandular 
tubes  there  is  still  a  certain  quantity  of  normal  interglandular  tissue. 
The  glandular  and  the  muscular  layers  are  clearly  defined,  and  the 
glands  have  no  tendency  to  penetrate  into  the  muscular  parenchyma 
and  destroy  it. 

In  malignant  adenoma  (Fig.  197),  on  the  contrary,  the  proliferation 
of  the  glands  is  atypical ;  furnished  with  a  single  layer  of  cylindrical 
epithelial  cells,  they  are  folded  upon  themselves  and  rolled  up  into 
glomeruli;  the  fibrous  substratum  has  almost  disappeared  and  the 
glands  touch  each  other  at  many  points ;  and  there  is  no  boundary 
between  the  glands  and  the  uterine  tissue. 

The  figure,  borrowed  from  Ruge  and  Veit,3  reproduces  the  initial 
lesions  of  cancer  derived  from  malignant  adenoma,,  forming  thus  the 
last  stage  which  I  have  described  in  the  pathological  progression. 
The  lumen  of  the  glands  is  enlarged  at  the  expense  of  the  inter- 
glandular substance,  the  beautiful  epithelium  with  vibratile  cilia  has 
changed  its  form  and  become  stratified,  flattened,  and  enlarged  with 
an  epidermoid  aspect,  following  the  greater  or  less  rapidity  of  the 
proliferation,  and  the  gland  cells  also  stain  with  more  difficulty.  The 
space  which  the  gland  occupies  by  its  increase  may  be  fifty  times  that 
of  its  original  volume.  The  epithelial  proliferation  may  begin  upon 
one  of  the  walls  and  fill  the  cavity  little  by  little,  so  that  at  last  there 
remains  but  an  insignificant  portion  still  covered  with  a  single  layer 


398 


CLINICAL    AKD    OPERATIVE    GYNAECOLOGY. 


of  epithelium ;  or  it  may  start  from  the  whole  circumference  of  the 
gland  at  once  and  leave  the  cavity  persisting.  In  other  cases  the 
glandular  canal  disappears  so  that  there  is  only  a  solid  mass  of  cells. 
Finally  the  proliferation  of  the  cells  may  begin  from  many  points  at 
once  and  form  by  their  junction  a  series  of  bridges  which  divide  the 
cavity  into  several  compartments.  These  glands,  in  part  degenerated, 
form  the  last  term  between  those  which  are  still  normal  and  those 


Pig.  197.— Malignant  Adenoma  of  the  Uterine  Mucous  Membrane.    Beginning  Glandular  Epithelioma 

CRugeand  Veit). 

which  are  transformed  into  solid  cylinders,  stuffed  full  of  cancerous 
cells. 

As  regards  symptoms,  prognosis,  and  treatment,  malignant  adenoma 
is  identical  with  cancer  of  the  uterine  body. 

Cancer  of  the  Body  of  the  Uterus. 

Cancer  of  the  body  of  the  uterus  presents  various  anatomical  forms 
which  correspond  to  distinct  clinical  types,  as  follows: 
1.  Cancer  of  the  mucous  membrane: 

A.  Epithelioma  (French  authors). 

Carcinoma  (German  authors). 

B.  Sarcoma. 


CANCER   OF  THE   BODY   OF   THE   UTERUS.  399 

2.  Cancer  of  the  parenchyma  (fibro-sarcoma,  sarcomatous  fibroma). 

Primary  cancer  of  the  body  of  the  uterus  has  until  recently  been 
regarded  as  very  rare.  Gallard  found  but  two  cases  in  his  long  career,4 
and  Pichot 5  in  1876  could  collect  only  forty-four  cases  among  French 
and  English  authors. 

This  apparent  rarity  depends  upon  the  fact  that  the  older  gynae- 
cologists seldom  employed  exploratory  dilatation,  and  almost  never 
exploratory  curettage.  Thanks  to  the  modern  means  of  investigation 
we  now  know  that  primary  cancer  of  the  uterine  mucous  membrane 
is  far  more  frequent  than  had  been  thought  to  be  the  case ;  thus  Gus- 
serow  has  published  one  hundred  and  twenty-two  cases.  The  relative 
frequency  of  cancer  of  the  body  and  of  the  cervix  is,  according  to 
Szukitz,6  in  the  proportion  of  1  to  420.  More  recently,  Schroder 7  in 
812  cases  found  28  of  primary  cancer  of  the  body,  and  Schatz 8  among 
80  cases  found  2. 

I.  Epithelioma  or  Carcinoma  of  the  Mucous  Membrane. 

The  German  school  ordinarily  applies  the  term  carcinoma  to  the 
form  which  the  French  school9  now  designates  as  epithelioma.  I 
shall  consider  these  two  terms,  which  suggest  but  one  and  the  same 
lesion,  as  synonymous.  One  might  almost  describe  this  lesion  as  can- 
cer of  the  menopause,  in  view  of  its  great  frequency  at  that  epoch  of 
the  genital  life.  It  originates  in  a  transformation  from  the  conditions 
of  glandular  metritis,  suck  as  I  have  described,  which  may  be  followed 
step  by  step  in  the  same  patient  by  repeated  curettings.10 

Pathology. — Macroscopically  we  may  distinguish  two  varieties. 
In  the  one  there  is  a  diffuse  growth  of  villi  throughout  the  whole 
uterine  cavity,  which  gives  to  its  section  the  aspect  of  a  ripe  fig  (Figs. 
199  and  200);  in  the  other  there  is  an  isolated  fungoid  growth  with 
a  large  or  small  base,  which  at  times  has  the  form  of  a  polyp  (Fig.  198). 

It  is  worthy  of  note  that  the  neoplasm  has  little  tendency  to 
invade  the  mucous  membrane  of  the  cervix.  This  peculiarity  is  both 
an  added  difficulty  in  diagnosis  and  an  advantage  in  the  matter  of 
treatment.  The  uterine  wall,  on  the  contrary,  is  little  by  little  eroded 
and  destroyed.  Metastatic  nodules  form  in  various  points  of  the  paren- 
chyma, and  even  under  the  peritoneum,  causing  protective  adhesions 
of  that  membrane  between  the  uterus,  the  bladder,  and  the  intestines. 
Occasionally  fatal  peritonitis  has  been  caused  by  perforation.  Fre- 
quently these  metastatic  nodules  are  found  superficially  in  the  vagina 
and  deeply  in  the  ovaries,  tubes,  etc. 


400 


CLINICAL  AND   OPERATIVE   GYNAECOLOGY. 


Histologically  u  these  tumors  are  tubular  or  lobulated  epithelio- 
ruata  provided  with  tubes  which  for  the  most  part  are  very  large  aud 
form  anastomoses  with  each  other,  with  the  peculiarity  that  the  first 
layer  of  cells  implanted  upon  the  wall  is  regularly  cylindrical.  These 
cells  are  of  long  shape,  and  have  nuclei  which  stain  strongly.     The 

successive  layers  are  formed 
by  polyhedral  cells  which 
are  at  times  of  the  pave- 
ment variety.  The  most 
internal  become  mucous, 
cover  the  granulations,  and 
often  present  complete 
atrophy  of  their  nuclei. 


Fig.  198.— Epithelioma  of  the  Uterine  Mucous 
Membrane,  Circumscribed  Form. 


Fig.  199.— Epithelioma  of  the  Uterine  Mucous 
Membrane,  Diffuse  Form. 


When  a  section  is  examined  under  a  low  power  to  obtain  a  com- 
prehensive view  of  the  neoplasm,  a  number  of  alveoli  may  be  dis- 
cerned, whose  thin  walls  are  carpeted  by  cylindrical  epithelial  cells  in 
one  or  two  layers  only.  In  the  fresh  state,  large  cavities  are  also 
found  which  contain  a  mucous  liquid  holding  cells  in  suspension 
(Fig.  201).  .  It  is  easy  to  understand  the  method  of  formation  of  these 
cavities.  The  fibrous  wall  which  circumscribes  them  contains  capillary 
vessels  penetrating  into  the  epithelial  layer,  and  covered  by  it.  These 
vessels  present  vegetations  under  the  form  of  papillae  which  are  seen 
sometimes  cut  longitudinally,  sometimes  transversely,  in  which  lat- 


CANCER  OF  THE  BODY  OF  THE  UTERUS. 


401 


ter  case  they  appear  to  be  surrounded  by  cylindrical  cells.  There  are 
also  mucous  cavities  in  the  midst  of  the  epithelial  investment,  so  that 
certain  tubes,  originally  narrow,  are  transformed  into  large  cavities. 

With  the  higher  powers  the  conditions  are  more  easily  understood 
(Figs.  202  and  203).  Beside  the  lesions,  which  are  wholly  epithelioma- 
tous,  the  alterations  of  chronic  metritis  are  almost  constantly  found. 
To  avoid  errors  many  sections  should  be  examined,  and  not  merely  a 
few  small  fragments. 


<  MZMAfSAI 


Fig.  300.— Epithelioma  of  the  Uterus;  Diffuse  Form,  with  Circumscribed  Thickening,     a,  Muscular 
wall  of  the  uterus;  b,  e,  section  of  neoplasm;  c,  surface  of  neoplasm;  d,  cervix,  not  involved. 


The  great  quantity  of  cylindrical  cells  in  these  tubular  or  lobu- 
lated  formations  distinguishes  these  epitheliomata  of  the  uterus  from 
ordinary  tubular  pavement  epitheliomata,  such  as  are  found  in  the 
integument.  They  are  in  reality  a  special  form,  peculiar  to  the 
mucous  membrane  where  they  are  developed. 

At  an  advanced  stage  of  evolution,  cancer  of  the  body  of  the  uterus 
may  ulcerate,  or,  as  Cornil  has  found,  the  mucous  membrane  may  be 
preserved  and  merely  elevated  by  the  epithelial  lobules. 

The  mucous  membrane  of  the  body  of  the  uterus  is  usually  easily 
recognized,  for  its  epithelial  cells  are  preserved  although  covered  by 
certain  wandering  cells,  but  its  glands  are  atrophied  and  their  cylin- 
drical cells  are  very  small,  the  connective  tissue  being  thin  and  com- 


402 


CLINICAL   AND   OPEKATIVE   GYNAECOLOGY. 


pressed.  In  other  23laces  the  mucous  membrane  is  reduced  to  a  very 
thin  layer  of  connective  tissue  lined  by  one  simple  layer  of  cylindri- 
cal cells  (Fig.  204). 

At  a  later  period  the  muscular  layers  are  infiltrated  by  the  neo- 
plasm, and  there  may  also  be  extension  to  the  tubes  and  ovaries. 

I  have  described  as  a  unique  anatomical  curiosity  a  case  of  pri- 
mary pavement  epithelioma  of  the  body  of  the  uterus,  observed  by 
O.  Piering.12 


Fig.  201. — Epithelioma  of  the  Uterus.  X  120.  6,6,  Lobules  of  the  epithelioma;  m,  lobules  showing 
empty  spaces,  which  are  either  transverse  sections  of  vessels  or  cavities  filled  with  cells  in  mucous  degen- 
eration; n,  smaller  alveoli  of  the  epithelioma.  Nearly  all  of  these  epithelial  cells  have  a  tendency  toward 
isolation  by  the  walls  of  the  spaces  that  enclose  them. 


Symptoms. — Hemorrhage  is  the  primary  symptom,  and,  as  in  can- 
cer of  the  cervix,  it  is  usually  accompanied  by  a  serous  discharge 13  of 
a  reddish  color  and  a  stale,  disagreeable  odor;  with  this  there  is  often 
a  discharge  of  small  shreds  of  tissue  from  the  broken  fungosities. 

The  pains  and  the  other  functional  and  reflex  symptoms  are,  for 
a  long  time,  those  which  I  have  described  under  the  head  of  the  uter- 
ine syndroma  (vide  metritis) ;  but  according  as  the  disease  becomes 
more  advanced  the  pain  takes  on  a  paroxysmal  character  which  is  re- 
markable and  almost  pathognomonic.  These  crises  of  excruciating 
pain  described  by  Simpson  are  wrongly  attributed,  I  think,  by 
Schroder  to  contractions  of  the  uterus  caused  by  the  effort  to  expel 


CANCER  OF  THE  BODY  OF  THE  UTERUS. 


403 


its  abnormal  contents.  They  have  none  of  the  characters  of  colic, 
and  their  appearance  at  regular  hours  once  or  twice  a  day,  even  after 
the  tumor  has  been  destroyed  by  the  curette,  as  I  have  observed, 
proves  clearly  that  they  are  due  to  a  veritable  neuritis  propagated 
along  the  nerves  of  the  disorganized  nterus. 

Bimanual  palpation  determines  that  the  organ  is  much  increased 
in  volume,  being  as  large  at  times  as  the  pregnant  uterus  at  the 
fourth  month.    It  remains  movable  for  a  long  time,  but  finally  becomes 


kMSS 


Fig.  202.— Epithelioma  of  the  Body  op  the  UTERrs.  High  power,  c.  Connective  tissue;  d,  glandular 
cul-de-sac,  but  little  altered;  /,  g.  m,  dilated  and  modified  glands.  Their  investment  is  formed  of  cylindrical 
cells,  /,  but  their  cavity  is  full  of  cells,  m,  g,  and  the  glandular  membrane  is  wanting,  a.  Large  cavity  in 
the  middle  of  an  island  of  epithelioma.  The  epithelial  mass  is  pierced  by  vessels  which  belong  to  the 
adjacent  connective  tissue,  as  seen  at  v,  v,  m,  oblique  sections  of  the  same  vessels  (Cornilj. 


imprisoned  by  adhesions  in  the  pelvis.  By  touch,  the  cervix  is  found 
to  be  free  from  the  disease,  but  often  much  softened  and  partly  open. 
as  in  the  case  of  the  gravid  uterus. 

The  sound,  which  should  be  used  with  much  precaution,  reveals 
an  increase  in  the  capacity  of  the  uterus,  and  the  presence  of  irregu- 
lar masses.  At  times  the  cervix  may  be  sufficiently  dilated  for  the 
finger  to  feel  these  f  ungosities  within  the  uterus ;  if  not,  an  artificial 
rapid  dilatation  will  confirm  the  diagnosis. 

The  condition  of  the  general  health  fails  as  the  neoplasm  develops 
and  terminates  in  cachexia. 


404 


CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 


Diagnosis. — The  hemorrhage,  the  serous  discharge,  the  increase 
in  the  volume  of  the  uterus,  and  the  results  of  intra-uterine  explora- 
tion constitute  the  clinical  elements  of  the  case,  while  the  examination 
of  portions  removed  by  the  curette  clearly  differentiates  between  can- 
cer and  metritis  without  malignant  neoplasm,  or  between  carcinoma 
and  sarcoma. 

It  is  in  these  cases,  however,  that  we  encounter  the  greatest 
difficulties  in  the  differential  diagnosis  between  cancer  and  metritis. 
With  all  the  common  rational  signs,  and  especially  persistent  hem- 
orrhage which  has  resisted  the  curette,  we  have  only  the  resist- 
ance of  the  disease  to  therapeutic  measures  and  the  examination 


Fig.  203. — Primary  Epithelioma  op  the  Uterine  Body.  X  300.  a,  Numerous  layers  of  stratified 
epithelium,  the  deepest  being  cylindrical;  e,  e,  cells  with  karyokinesis ;  t,  muscular  tissue  of  the  uterus, 
on  which  the  cylindrical  cells  are  directly  implanted  (Cornil). 

of  small  particles  removed  by  the  curette  to  enable  us  to  decide  the 
nature  of  the  lesion.  As  Cornil 14  has  justly  remarked,  although  his- 
tological diagnosis  is  easy  when  we  have  the  whole  uterus  to  examine, 
it  is  otherwise  when  we  can  secure  only  small  fragments  of  the 
mucous  membrane.  The  simple  glandular  hypertrophy  of  metritis 
may  then  be  very  difficult  to  distinguish  from  carcinoma,  especially 
when  the  mucous  membrane  of  the  glands  cannot  be  examined  in  the 
deeper  parts.  In  the  simple  glandular  hypertrophies  there  often 
exists  between  the  culs-de-sac  and  the  connective  tissue  a  very  regular 
layer  of  flat  cells  which  serve  as  the  membrane  of  implantation  for 
the  epithelium.  The  vibratile  cilia  are  almost  always  preserved  and 
are  found  to  the  bottom  of  the  gland.  The  mucous  transformation  of 
the  cells  is  never  complete,  but  occupies  only  their  free  extremities. 
The  interglandular  tissue  is  less  charged  with  lymph  cells,  but  in  the 


CANCER   OF  THE   BODY   OF   THE   UTERUS. 


405 


epithelioma  and  the  layers  of  young  connective  tissue  they  are  ar- 
ranged in  regular  lines  which  follow  parallel  to  the  excretory  ducts. 
In  the  epitheliomata,  on  the  contrary,  there  is  at  the  same  time  a  hy- 
pertrophic elongation  of  the  glands  and  a  multiplication  of  cells  which 
rajjidly  lose  the  type  of  ciliated  epithelium.  As  a  result  of  this 
proliferation  the  lower  part  of  the  gland  is  filled  full  with  an  epithe- 
lial mass.  The  cells  may  either  undergo  a  mucous  transformation  or 
take  on  the  polyhedral  or  cuboid  form.  As  soon  as  the  walls  of  these 
glands  are  ruptured,  the  tumor  presents  the  general  disposition  of 
epithelioma  or  carcinoma. 

It  may  happen  then,  that  as  a  last  resort  against  the  persistent 
hemorrhage  which  threatens  the  life  of  the  patient,  we  are  obliged 
to  perform  vaginal  hysterectomy  with  only  a  diagnosis  of  probable 


Fig.  204.—  Mucous  Membrane  of  the  Cervix  Compressed  and  Atrophied  by  a  Cancer  Developed  in 
the  Deeper  Layers.  X  300.  e,  e,  Mucous  cells  of  the  clear  epithelial  investment,  no  longer  having  cilia; 
a,  wandering  cell  on  the  surface  of  the  epithelium;  b,  a  desquamated  epithelial  cell;  t,  connective  tissue 
of  the  mucous  membrane  compressed  by  the  tumor;  v,  vessels;  g,  glandular  tube  (Cornil). 


cancer,  but  beforehand  we  must  carefully  assure  ourselves  by  exam- 
ination of  the  adnexa  that  they  are  not  the  cause  of  a  reflex  hemor- 
rhage. Occasionally,  we  can  determine  ujjon  the  organ  so  removed 
the  presence  of  the  characteristic  lesions  of  epithelioma  which  were 
not  demonstrable  from  the  fragments  obtained  by  the  curette.  Mar- 
tin and  Lohlein 13  have  published  cases  of  this  nature  which  are  very 
instructive  to  the  clinician. 

A  fibroma  which  is  undergoing  cancerous  degeneration  may  be 
recognized  by  the  aid  of  the  microscope.  The  presence  of  metastatic 
nodules  of  a  cancerous  nature  in  the  vagina  will  render  the  diagno- 
sis clear. 

The  prognosis  is  grave ;  nevertheless,  an  early  operation  has  been 
followed  by  a  long  survival. 

Etiology. — This  form  of  primary  cancer  of  the  uterus  is  found 
chiefly  in  women'  who  have  reached  the  menopause,  the  average  age 


406 


CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 


according  to  Hofmeier  being  fifty-four  years.  Among  thirty -one  cases 
of  malignant  tumor,  comprising  many  varieties  which  Pichot  re- 
moved,17 only  nine  were  below  the  age  of  fifty ;  in  but  one  case  was 
the  influence  of  heredity  manifestly  present;  nulliparae  were  far  more 
frequently  attacked  than  in  the  case  of  cervical  cancer.  Only 
twenty-one  per  cent  of  Hofmeier's  cases  had  never  had  children. 

II.  Diffuse  Sarcoma  of  the  Mucous  Membrane. 

Following  Virchow,  the  name  of  diffuse  sarcoma  is  given  to  thick- 
ening of  the  mucous  membrane  by  proliferation  of  round  or  fusiform 


Fig.  205. — Sarcoma  of  the  Uterine  Mucous  Membrane. 

cells  which  infiltrate  it  and  reproduce  the  type  of  young  connective 
tissue,  producing  soft  villous  or  lobulated  tumors  of  an  encephaloid 
aspect.  This  form  of  cancer  is  found  most  frequently  in  young 
women. 

Pathology. — There  is  no  need  of  dwelling  upon  the  microscopic 
characters  of  sarcoma  which  here  present  nothing  of  special  interest 
(Fig.  206),  except  to  notice  that  the  histological  elements  of  sarcoma 
and  cancer  have  occasionally  been  united  in  the  same  tumor,  thus 
constituting  a  mixed  form  or  carcino-sarcoma  (Klebs). 


CANCER  OF  THE  BODY  OF  THE  UTERUS. 


407 


When  the  sarcoma  forms  a  pedicled  tumor  it  may  present  in  the 
cervix  like  a  polyp.18  Its  ulceration  and  disintegration  are  more 
rapid  than  in  the  case  of  epithelioma,  and  when  the  jjrocess  has  ke_ 
gun  it  may  destroy  the  uterine  parenchyma. 

Abel, 19  as  I  have  already  mentioned,  affirms  that  diffuse  sarcoma 
of  the  body  of  the  uterus  often  coexists  with  circumscribed  epithe- 
lioma of  the  cervix,  but  he  seems  to  have  taken  a  purely  inflamma- 
tory lesion  for  a  sarcomatous  growth. 

Symptoms  and  Diagnosis.— The  symptoms  resemble  in  many 
particulars  those  of  the  preceding  form.  There  is  hemorrhage,  a 
serous  discharge,  and  increase  in  the  size  of  the  uterus.     The  intro- 


Fig.  206.— Diffuse  Sarcoma  of  the  Uterine  Mucous  Membrane.  The  neoplasm  is  separated  from  the 
peritoneum  on  the  left  by  a  well-marked  layer  of  healthy  muscular  tissue  several  millimetres  thick ;  the 
superficial  portions  toward  the  cavity  of  the  uterus,  on  the  right,  are  beginning  to  disintegrate.  In  the 
deeper  parts  are  seen  the  connective-tissue  fibrils,  rich  in  fusiform  cells  with  long  and  short  processes. 
Between  them  is  an  amorphous  basement  substance  with  a  large  accumulation  of  round  cells  whose-nuclei 
appear  to  resemble  those  of  the  others.  In  the  superficial  portions  the  bands  of  connective  and  muscular 
tissue  have  entirely  disappeared,  being  replaced  by  round  cells.  The  tumor  is  very  rich  in  vessels,  about 
which  are  foci  of  hemorrhage.  In  no  part  of  the  tumor  can  we  find  any  trace  of  either  mucous  membrane 
or  gland  (Wyder). 


duction  of  the  finger  discovers  the  neoplasm.  The  cervix  is  not  in- 
volved. But  sarcoma  is  distinguished  from  epithelioma  by  the  fol- 
lowing clinical  characters.  The  discharge  is  less  fetid  during  the  early 
stages,  the  ulceration  appears  later,  and  the  cervix  is  not  so  much 
dilated;  possibly  also  a  polypoid  tumor  may  be  found  opening  the 
cervix  and  descending  into  the  vagina,  at  times  causing  inversion  of 
the  uterus.  For  the  diagnosis  from  other  diseases  I  refer  to  the  pre- 
ceding form. 

Prognosis. — This  is  very  grave,  fatal  recurrence  being  observed 
even  when  an  early  operation  has  been  performed.20 

Etiology— One  of  the  most  remarkable  characters  which  separates 


408  CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 

this  neoplasm  from  epithelioma,  is  the  age  at  which  it  occurs, 
there  being  many  cases  of  it  among  women  of  less  than  twenty 
years.  Zweifel21  has  reported  one  case  of  hysterectomy  performed 
for  uterine  sarcoma  in  a  child  of  thirteen.  •  It  especially  attacks  nulli- 
parae. The  first  histogenetic  stage  seems  to  be  an  interstitial  endome- 
tritis. As  this  has  so  often  been  observed  in  the  body  of  the  uterus 
when  the  cervix  is  the  seat  of  epithelioma,  it  is  conceivable  that  the 
metritis  may  transform  itself  into  sarcoma,  according  to  the  still  dis- 
puted opinion  of  Abel,  whence  the  frequent  coexistence  of  these  two 
different  neoplasms  in  the  same  uterus. 

III.  Fibrosarcoma. 

Synonyms:  Sarcoma  fibrosum  seu  nodosum,  circumscribed  fibro- 
sarcoma, sarcoma  of  the  uterine  parenchyma. 

Pathology. — From  a  clinical  point  of  view  this  form  might  be 
called  malignant  fibroma;  like  its  benign  homologues,  it  occurs  as  a 
submucous,  interstitial,  or  subserous  tumor.  Like  them  also  it  takes 
its  origin  in  the  parenchyma  of  the  uterus;  but  instead  of  being  lim- 
ited by  a  loose  capsule  it  is,  as  a  distinctive  characteristic,  deeply 
rooted.  On  section  its  surface  is  pale  and  its  consistence  homoge- 
neous and  soft.  When  it  has  a  pedicle  it  is  apt  to  be  fibrous,  showing 
that  it  has  come  from  a  degenerated  fibro-muscular  polyp.  The  ves- 
tiges of  a  structure  which  was  at  first  benign  may  at  times  be  recog- 
nized in  the  sessile  tumors,  but  in  others  the  characteristic  tissue  of 
sarcoma— namely,  the  accumulation  of  round  cells,  in  places  fusiform — 
is  traversed  by  a  few  bands  of  connective  tissue.  It  is  very  proba- 
ble that  a  fibro-sarcoma  always  originates  in  a  fibro-myoma;  this  de- 
generation may  often  be  detected,  as  the  remarkable  observations  of 
Chrobak,  Muller,  Simpson,  Frankenhauser,  and  Kurz22  demon- 
strate. 

Metastatic  nodules  have  been  observed  in  the  vagina,  the  peri- 
toneum, the  lung,  the  liver,  and  the  vertebras. 

Transformation  of  fibro-sarcoma  into  myxo-sarcoma,  cysto-sarcoma, 
and  other  mixed  forms  is  exceedingly  rare,23  of  which  a  remarkable 
case  of  Gusserow's  of  a  myxo-sarcoma  with  metastasis  to  the  perito- 
neum, and  another  of  Rabl-Riickhardt's,  where  there  was  a  combina- 
tion of  carcinoma  and  fibro-sarcoma,24  are  noteworthy  examples;  the 
partisans  of  the  proposition  defended  by  R.  Maier 25  might  even  see 
here  a  proof  of  the  direct  transformation  of  sarcoma  into  carcinoma. 


CANCER   OF   THE   BODY   OF   THE   UTEKUS.  409 

Symptoms. — At  first  nothing  distinguishes  fibrosarcoma  from  a 
benign  fibroma,  the  signs  being  hemorrhage  under  the  form  of  men- 
orrhagia  or  metrorrhagia,  with  a  serous  discharge,  a  non-odorous  hy- 
drorrhea, moderate  pain  and  increase  in  the  size  of  the  uterus.  The 
physical  phenomena  are  those  of  a  non-ulcerated  tumor  which  may 
be  reached  by  the  finger  if  the  cervix  is  dilated  and  the  tumor  sub- 
mucous. 

Later  on,  ulceration  of  the  neoplasm  alters  the  scene ;  the  bleeding 
becomes  an  almost  continuous  oozing ;  the  leucorrhcea  has  a  fetid  odor 
and  contains  debris  which  under  the  microscope  is  found  to  be  made 
up  of  sarcomatous  tissue;  the  pain  increases  and  takes  on  a  regular 
paroxysmal  character,  as  already  described  under  carcinoma  of  the 
mucous  membrane.  Local  examination  by  the  finger  in  the  intact 
but  dilated  cervix  permits  us  to  feel  the  tumor  which  projects  between 
the  lips  of  the  organ.  The  uterus  may  be  greatly  increased  in  size 
and  is  often  retroverted  and  rendered  immovable  during  the  later 
periods  of  the  disease.  Inversion  of  the  uterus  has  also  been  observed 
as  a  consequence  of  sarcoma  (Simpson).  The  cachexia  becomes  pro- 
gressively more  pronounced. 

Frequently  this  second  phase  is  preceded  by  a  temporary  improve- 
ment due  to  the  removal  of  the  tumor  under  the  idea  that  it  is  a 
simple  fibroma,  but  even  during  the  operation  there  is  a  suspicion 
that  it  may  be  of  a  more  serious  character  because  of  the  intimate 
fusion  with  the  adjacent  tissues  which  renders  enucleation  impossi- 
ble. A  rapid  recurrence  leaves  no  room  for  doubt ;  this  character  is 
so  pronounced  that  English  authors  have  termed  it  "recurrent  fibroid." 
Freund  has  observed  one  very  curious  case  of  fibro-sarcoma  in  an 
atresic  uterus  which  had  caused  hydrometra. 

Diagnosis. — The  suspicions  to  which  the  rational  and  general 
symptoms  give  rise  are  rendered  certainty  by  the  finger  introduced 
deeply  into  the  uterus,  after  dilatation  if  necessary.  The  only  condi- 
tion with  which  it  might  be  confounded  at  the  outset  would  be  hem- 
orrhagic metritis  or  fibroma.  Later  in  the  course  of  its  development  it 
might  resemble  a  sloughing  fibroma,  an  epithelioma,  or  a  sarcoma  of 
the  mucous  membrane.  The  examination  by  the  microscope  of  frag- 
ments removed  by  the  curette  would  be  of  valuable  assistance  in  de- 
ciding the  question. 

The  duration  of  the  disease  varies  from  four  months  (Franken. 
hauser)  to  ten  years  (Hegar) ;  the  average,  according  to  Regivue,  is 
three  years. 


410 


CLINICAL  AND   OPERATIVE   GYNAECOLOGY. 


The  prognosis  varies,  but  is  always  serious;  the  disease  recurs  most 
quickly  in  young  patients  and  with  tumors  of  a  very  rapid  develop- 
ment. 

Etiology.— From  all  the  cases  published  up  to  1885,  G-usserow  de- 
rived the  following  table,  which  shows  the  influence  of  age: 


Before  20, 

From  20  to  30, 
"  30  "  39, 
"  40  "  49, 
"      50  u  60, 

Above  60,    . 


4  cases 

5 
15 
28 
18 

3 


(of  which  1  case  was  at  72  years). 
This  table  demonstrates  the  predisposition  created  by  the  meno- 
pause as  in  the  case  of  other  malignant  growths.  In  74  cases  ana- 
lyzed by  the  same  author  in  regard  to  fecundity  and  sterility,  there 
were  23  women  sterile,  of  whom  4  were  virgins.  This  proportion 
seems  very  high  and  forms  a  contrast  with  that  which  I  have  said  as 
to  the  predisposition  of  multiparae  to  cancer  of  the  cervix. 

Treatment  of  Cancer  of  the  Body  of  the  Uterus. 

There  is  no  great  difference  in  the  treatment  of  the  various  forms 
of  cancer  of  the  uterus,  that  which  follows  applies  as  well  to  epithe- 
lioma as  to  sarcoma. 

The  indications  are  the  same  as  for  cancer  of  the  cervix.  Per- 
form a  radical  operation  wherever  there  is  reason  to  hope  that  the 
disease  may  be  removed  entire  and  the  gravity  of  the  operation  is 
justified  by  the  great  benefits  which  are  to  be  derived  from  it;  in 
other  cases  limit  the  interference  to  palliative  treatment. 

The  method  of  choice  is  vaginal  hysterectomy  performed  as  early 
as  possible,  before  there  is  much  enlargement  of  the  uterus.  Schroder 26 
advises  us  to  remove  by  the  vagina  a  tumor  which  does  not  exceed 
the  volume  of  the  fist ;  and  though  by  fractional  excision  we  can  ex- 
tract much  larger  tumors,  yet  when  there  is  a  cancerous  uterus  the 
chances  of  infection  are  so  great  that  it  should  not  be  done.  It  is  to 
be  noted  that  the  immediate  success  of  the  vaginal  operation  is  much 
facilitated  by  the  fact  that  the  cervix  is  normal,  so  that  there  is  but 
little  risk  of  infecting  the  wound.27 

If  the  uterus  is  too  large  to  be  removed  by  the  vagina,  and  we  are 
unwilling  to  attempt  a  succession  of  curettings  and  cauterization, 
we  may  have  recourse  to  the  sacral  operation  which  I  have  described 


CANCER   OF   THE   BODY   OF   THE   UTERUS.  411 

in  the  preceding  chapter,  but  this  method  is  still  too  recent  for  final 
judgment.  Up  to  the  present  time,  when  the  uterus  has  been  too 
large  for  vaginal  extraction  the  custom  has  been  to  remove  it  through 
an  abdominal  incision.     Two  methods  may  be  needed: 

1.  If  the  cervix  has  remained  healthy,  we  may  excise  the  fundus 
and  use  the  cervix  for  a  pedicle;  in  other  words,  perform  a  supra- 
vaginal hysterectomy  (which  should  not  be  confounded  with  total 
hysterectomy).  But  unfortunately  the  cervix  will  furnish  a  stump 
which  is  far  too  short  to  be  fixed  externally,  and  it  must  therefore  be 
abandoned  within  the  peritoneal  cavity,  sutured  by  Schroder's  method 
as  described  under  the  head  of  myoma.  We  must  determine  before- 
hand that  it  is  healthy,  and  curette  its  interior  and  cauterize  it  with 
the  thermo-cautery. 

Abdominal  hystercetomy  for  cancer  of  the  uterus  in  Schroder's 
hands  has  given  4  deaths  in  18  cases,  or  39$. 28 

Rapid  return  of  the  disease  is  a  priori  to  be  feared  from  the  fact 
that  the  section  of  the  cervix  necessarily  goes  so  near  to  the  altered 
tissues.  However,  in  11  cases  of  cure  by  Schroder  3  only  succumbed 
to  a  recurrence  during  the  first  year,  4  were  still  in  good  health 
after  two  years,  and  1  after  five  years.  In  the  last  edition  of  his 
book,  Schroder  speaks  of  one  cure  dating  from  five  and  one  from  seven 
years  before,  which  evidently  belonged  to  the  same  series. 

2.  If  the  uterus  is  very  large  and  the  cervix  is  involved,  we  can 
no  longer  do  the  supra -vaginal  operation,  but  must  perform  total  ex- 
tirpation by  the  abdominal  method.29  This  operation  was  formerly 
employed  for  all  cancers  of  the  cervix  and  body,  but  by  reason  of  its 
alarming  mortality  there  was  a  return  to  the  vaginal  method  as  far  less 
dangerous.  The  operation  of  Freund  as  actually  performed  is  only  a 
return  to  a  method  proposed  by  Delpech 30  in  1830  (combining  the  hy- 
pogastric with  the  vaginal  method).  The  typical  operation  of  Freund 
as  described  in  his  first  writings  is  no  longer  practised  without  the 
modification  which  was  suggested  by  Rydigier 31  and  which  consists 
in  freeing  the  cervix  completely  by  the  vagina  before  opening  the 
abdomen.     The  perfected  operation  is  performed  as  follows: 

The  patient  is  placed  in  Trendelenburg's  position  after  the  prepa- 
ration which  I  have  described  for  vaginal  hysterectomy. 

After  the  first  and  the  second  steps  are  executed,  a  tampon  of  iodo- 
form gauze  is  placed  in  the  vagina. 

Third  Step.  Opening  the  Abdomen.— The  incision  begins  at  the 
umbilicus  and  extends  to  a  finger's  breadth  above  the  pubes.    It  is  well 


412  CLINICAL   AND    OPEEATIYE    GYNAECOLOGY. 

to  suture  the  abdominal  wall  in  mass  at  each  side  of  the  lower  angle 
of  the  wound  to  avoid  laceration  or  stripping  of  the  peritoneum.  If 
the  abdominal  wall  is  very  rigid,  one  or  both  of  the  recti  muscles  may 
be  severed  near  their  insertion.  Crede 32  has  proposed  a  very  bold 
plan  for  the  purpose  of  gaining  more  room,  namely,  the  resection  of  a 
part  of  the  pelvic  wall.  The  intestines,  which  have  a  tendency  to  fall 
toward  the  diaphragm  from  the  position  of  the  patient,  are  held  in 
that  place  by  gauze  compresses ;  but  if  there  is  no  other  way  of  ob- 
taining room  enough,  a  portion  of  the  intestine  may  be  drawn  out  of 
the  wound  and  kept  warm  and  moist  by  frequently  renewed  gauze 
compresses. 

Fourth  Step.  Ligation  and  Section  of  the  Broad  Ligaments. — 
The  uterus  is  seized  with  a  Museux  forceps  and  drawn  strongly  out  of 
the  abdomen.  Freund  then  ties  the  broad  ligaments  in  three  portions. 
In  passing  the  lowest  thread  which  is  to  include  the  uterine  artery, 
he  uses  a  needle-trocar  whose  point  can  be  pushed  out  of  a  canula 
and  then  retracted  Avithin  it.  When  the  operation  has  been  begun 
by  the  vagina,  this  step  is  much  simplified,  for  the  uterine  artery  has 
already  been  tied  from  below.  This  preliminary  has  also  the  enorm- 
ous advantage  of  enabling  us  to  avoid  the  ureters  more  certainly, 
though  it  is  also  possible  to  see  them  after  the  abdomen  has  been 
opened.  The  vessels  having  been  ligated,  the  broad  ligaments  are 
divided  and  the  uterus  removed.  The  separation  from  the  bladder 
should  be  conducted  with  the  greatest  care  after  incision  of  the  peri- 
toneal pouch.  If  the  patient  is  young,  the  ovaries  and  tubes  should 
be  removed  with  the  uterus 

Fifth  Step.  Dressing. — As  in  colpo-hysterectomy,  the  stumps  of 
the  broad  ligaments  are  best  sutured  to  the  edges  of  the  vaginal  inci- 
sion, whose  size  is  somewhat  diminished  by  two  points  of  suture, 
then  the  toilet  of  the  peritoneum  is  to  be  carried  out,  the  abdominal 
wound  closed,  and  iodoform  gauze  placed  in  Douglas'  pouch  and  in 
the  vagina. 

Freund  prefers  to  close  the  vaginal  wound  by  carefully  suturing 
its  edges  to  the  peritoneum  above,  passing  the  sutures  by  the  vagina 
and  exercising  strong  traction  on  the  ligatures  of  the  superior  portion 
of  the  ligaments,  causing  their  inversion,  so  that  there  shall  be  a 
large  cicatricial  mass  in  the  place  of  the  uterus  between  the  bladder 
and  the  rectum. 

Bardenheuer  employs  a  very  complicated  method  of  drainage;33 
the  most  recent  is  a  triple  tube  for  the  vagina  of  which  the  middle 


CANCER  OF  THE  BODY  OF  THE  UTERUS.  413 

piece  is  fenestrated  and  in  communication  with  four  branches  which 
are  placed  in  the  peritoneal  cavity;  one  of  these  may  be  brought 
through  the  abdominal  opening. 

Martin 34  advises  that  the  order  which  I  have  given  be  reversed, 
first  removing  the  fundus  by  laparatomy  and  then  the  cervix  by  the 
vagina.  He  has  performed  this  operation  three  times  with  two 
deaths,  while  the  third  patient  died  of  a  return  of  the  tumor  within 
the  first  year. 

The  statistics  which  Hegar  and  Kaltenbach  have  given  in  1881 
comprise  93  cases,  with  63  deaths,  or  71$.  In  the  last  edition  of  their 
work  (1886)  they  have  presented  the  following  figures:  in  119  cases 
there  were  80  deaths,  or  67.2$ ;  also  4  operations  which  were  not  com- 
pleted and  1  whose  result  is  unknown,  that  is,  5  which  may  be  counted 
as  among  the  fatal  cases.  The  tumors  recur  very  rapidly  and  in  almost 
every  case.  The  preceding  authors  do  not  know  of  more  than  a  single 
case  of  permanent  cure,  namely,  a  patient  operated  upon  by  Freund 
in  1878.  Whenever  they  could  follow  the  case  long  enough  they  al- 
ways saw  a  return  of  the  disease  after  a  short  respite.  Total  extirpa- 
tion by  the  abdomen  is  then  an  operation  of  gravity  and  of  doubtful 
benefit;  and  for  my  part  I  prefer  the  sacral  method  when  vaginal 
hysterectomy  seems  to  be  impossible. 

When  the  limits  of  the  uterus  have  been  passed  by  the  growth  of 
the  tumor,  we  are  confined  in  our  efforts  to  merely  palliative  treat- 
ment, the  curette  and  cauterization  (see  chapter  on  treatment  of  can- 
cer of  the  cervix). 

Strict  antisepsis  of  the  vaginal  and  uterine  cavities  is  here  of  great 
importance,  for  the  products  of  the  disintegration  of  the  neoplasm 
have  but  one  means  of  exit — by  the  cervical  canal — and  by  their  pres- 
ence in  these  cavities  they  may  produce  the  symptoms  of  putrid  in- 
toxication. I  have  seen  patients  who  appeared  absolutely  septicsemic 
return  to  life,  so  to  speak,  after  the  use  of  the  curette,  antiseptic  tam- 
pons of  iodoform,  and  persevering  intra-uterine  irrigation.  Many  of 
these  cases  are  described  in  the  thesis  of  my  brother,  Adrien  Pozzi.35 
The  sublimate  solution  1 : 5,000  is  here  more  or  less  dangerous  on 
account  of  the  large  absorbing  surface.  It  must  therefore  always  be 
followed  by  the  use  of  filtered  and  boiled  water,  which  is  simply 
aseptic.  For  a  more  energetic  disinfectant  I  am  accustomed  to  em- 
ploy injections  of  a  cherry-red  solution  of  permanganate  of  iDotash 
and  as  a  deodorant  one  to  two  tablespoonfuls  to  the  litre  of  Labar- 
raque's  solution.  * 


414  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

In  the  case  of  acute  septicemic  intoxication  great  benefit  may  be 
obtained  from  the  introduction  of  small  strips  of  iodoform  gauze  into* 
the  uterine  cavity,  leaving  them  in  place  twenty-four  to  forty-eight 
hours  as  a  rapid  and  energetic  means  of  disinfection.  Antiseptic 
tamponing  of  the  uterus  has  been  recommended  by  Fritsch 36  after 
curetting  for  cancer,  both  as  an  antiseptic  and  as  a  haemostatic. 


BIBLIOGRAPHY. 

1.  Carl  Huge:  Ueber  Adenoma  Uteri.  Verhandl.  Deutsch.  (resell,  zu  Halle, 
May,  1888,  p.  195. 

2.  As  an  example  of  the  abuse  of  words  which  is  caused  by  the  employment  of 
the  term  adenoma,  see  especially  the  numerous  German  observations.     F.  Schatz: 
Ein  Fall  von  Fibroadenoma  Cystic,  et  Polypos.  Corp.  et  Colli  Uter.     Arch.  f.  Gyn. 
Bd.  xxii.,  p.  456. 

3.  Ruge  and  Veit:  Zeit.  f.  Geb.  und  Gyn.,  Bd.  vi.,  p.  302. 

4.  T.  Gallard:  Lecons  Clin,  sur  les  Mai.  des  Fern,  2d  ed.,  p.  946. 

5.  L.  Pichot:    Etude  clin.  sur  le  Cancer  du  Corps,  etc.,  Paris,  1876. 

6.  Szukitz:  Zeit.  d.  Gesell  d.  Wien.  Aerzt.,  1857. 

7.  Hofmeier:   Zeit.  f.  Geb.  und  Gyn.,  Bd.  x. 

8.  Schatz:   Handb.  der  Path.  Anat.,  1876,  p.  867. 

9.  Cornil:  Lecons  sur  l'Anat.  Path,  des  Cancers  de  l'Uterus.  Journ.  des  Conn. 
Med.,  1888. 

10.  Breisky:  Prag.  med.  Woch.,  1877,  p.  78. 

11.  Cornil:   Lecons  sur  l'Anat.  Pathol,  des  Metrit.,  etc.,  Paris,  1889,  p.  136. 

12.  O.  Piering:  Ueber  einen  Fall  von  atypischen  Carcinom.,  etc.  Zeit.  f.  Heilk., 
Bd.  viii.,  1888. 

13.  Mile.  Coutzadrida:  De  l'Hydror.  et  de  sa  Valeur  Semeiologique,  etc.  Paris 
Thesis,  1884.  This  author  considerably  exaggerates  the  value  of  this  symptom,  which 
has  been  entirely  absent  in  some  of  my  cases. 

14.  Cornil  and  Brault :  Notes  sur  les  Lecons  de  TEndometr.  Chron.  Bui.  de  la 
Soc.  Anat.,  Jan.,  1888,  p.  57  et  seq. 

15.  Cornil,  cited  by  Valat:  Del'EpitheL  Primit.  du  Colde  FUter.  Paris  Thesis, 
1888. 

16.  Martin:  Cent.  f.  Gyn.,  1889,  No.  40,  p.  689.  LOhlein:  Ibid.  Ott:  Extirp. 
de  FUter.  par  le  Voie  Vag.    Ann.  de  Gyn.,  October  and  November,  1889,  p.  36. 

17.  Pichot:   De  l'Epith61ioma  Prim,  du  Corps,  etc.     Paris  Thesis,  1888. 

18.  Mund<5:   Myxofib.  of  the  Endometr.     Amer.  Jour.  Obst.,  1883,  xxi     \  63. 

19.  K.Abel:  Loc.  cit.  See  contradictory  article  by  E.  Frankel:  Arch  f  Gyn., 
Bd.  xxxiii.,  Hft.  1;  an  important  discussion  at  the  Berl.  Gyn.  Soc,  July  13th,  1888 
Cent.  f.  Gyn.,  1888,  p.  753;  and  a  long  paper  by  Thiem  at  61st  Cong.  German  Natur  , 
Sept.  23d,  1888,  Cent.  f.  Gyn.,  1888,  p.  762. 

20.  Freund:  Meeting  of  German  Naturalists  and  Physicians,  Heidelberg,  1889. 
Cent.  f.  Gyn.,  1889,  p.  695. 

21.  Zweifel:   Drei  Falle  vag.  Totalextirp.,  etc.    Cent.  f.  Gyn.,  1884,  p.  401. 

22.  Chrobak:  Arch.  f.  Gyn.,  Bd.  iv.,  p.  549.  G  Muller :  IbicT.,  vi.,  p.  126.  A. 
R.  Simpson:  Contrib.  to  Obst.  and  Gyn.,  p.  240.  Frankenhauser,  cited  by  Rogivue: 
Du  Sarcome  de  FUter.  Zurich  Thesis,  1876.  Kurz:  Deutsch.  Zeit.  f.  Pract.  Med., 
June  16th,  1877. 

23.  Gusserow:   Die  Neubild.  des  Uter.,  p.  165. 


CANCER   OF  THE  BODY   OF  THE   UTERUS.  415 

24.  Rabl-Riickhardt:  Beitrage  zur  Geb.  und  Gyn.,  1,  p.  76. 

25.  R.  Maier:   Virchow's  Arch.,  Bd.  lxx.,  p.  378. 

26.  Schroder:   Die  Krankh.  der  weibl.  Org.,  7th  edit.,  1889,  p.  319. 

27.  Routier:  Cong.  Franc,  de  Chir.,  1887  and  Soc.  de  Chir.,  Nov.,  1888.  Ter- 
rillon:  Repertoire  Univ.  d'Obst.  et  de  Gyn.,  1889,  p.  351.  Report  of  three  cases  of 
hysterectomy  for  malignant  tumors,  with  cure;  no  note  as  to  whether  he  has  also 
had  a  death. 

28.  Hofmeier:   Berlin  klin.  Woch.,  Nos.  6  and  7,  1886. 

29.  W.  A.  Freund:  Eine  neue  Meth.  der  Extirp.  d.  ganz.  Uter.  Samml.  klin. 
Vortrage,  No.  133.     Cent,  f.  Gyn.,  12,  1878. 

30.  Delpech:   Bullet,  de  V Acad,  de  MM.,  1830. 

31.  Rydigier:   Berl.  klin.  Woch.,  1876,  No.  45. 

32.  B.  Crede":   Cent.  f.  Gyn.,  1878,  No.  32. 

33.  Bardenheuer:   Zur  Frage  d.  Drain,  d.  Perit.,  Stuttgart,  1880. 

34.  Martin:  Path,  und  Therap.  d.  Frauenk.,  p.  320.  A.  Sippel:  Eine  Freund- 
sche  Totalextirp.  Cent.  f.  Gyn.,  1889,  No.  49.  A  successful  case  by  the  mixed 
method. 

35.  A.  Pozzi:   Le  Trait,  du  Cancer  de  l'Uter.     Paris  Thesis,  1888. 

36.  Fritsch:   Die  Krank.  der  Frauen,  1886,  p.  77. 


CHAPTEE  XYIL 

DISPLACEMENTS   OF   THE   UTERUS. 

The  uterus  is  connected  posteriorly  to  the  sacrum  by  the  utero- 
sacral  ligaments  whose  inextensible  and  resistant  fibres  are  at- 
tached to  the  organ  at  the  level  of  the  cervix.  Its  connections  with 
the  bladder  in  front  and  the  round  and  broad  ligaments  at  the 
sides  preserve  its  normal  position  of  slight  anteflexion,  which  it 
retains  as  a  vestige  of  its  foetal  condition.1  The  tonicity  of  the  pelvic 
floor,  of  which  the  only  weak  point  is  occluded  by  the  normal  con- 
traction of  the  vagina,  prevents  the  abdominal  contents  from  acting 
in  the  direction  of  their  weight ;  the  pressure  is  distributed  over  the 
whole  surface  and  the  uterus  floats  as  if  it  were  suspended  in  the 
midst  of  the  organs  of  the  lower  pelvis  which  act  as  cushions  for  it. 
When  the  uterus  is  artificially  drawn  downward,  this  state  of  the 
pelvic  contents  becomes  very  apparent,  for  up  to  the  moment  when  the 
utero-sacral  ligaments  are  stretched  and  oppose  any  farther  descent, 
the  organ  yields  with  but  gentle  resistance,  as  of  a  floating  body 
which  is  slowly  drawn  under. 

When  the  bladder  is  full,  it  pushes  the  uterus  backward,  so  that 
its  slight  curve  of  anteflexion  is  obliterated,  to  be  restored  and  exag- 
gerated when  the  organ  is  again  emptied.  The  rectum,  when  full, 
pushes  the  uterus  forward  and  upward  in  a  corrresponding  manner, 
though,  in  the  physiological  condition  this  motion  is  seldom  so  pro- 
nounced that  its  action  is  noticeable.  In  the  case  of  the  bladder,  how- 
ever, it  is  important,  especially  as  social  customs,  which  very  quickly 
become  organic  habits,  exaggerate  it  considerably. 

There  is  then  but  one  point  of  attachment  where  the  uterus  is  at 
all  firmly  fixed,  namely,  that  of  the  posterior  ligaments,  and,  as  they 
are  inserted  where  the  organ  is  thinnest,  evidently  its  position  may 
be  compared  to  that  of  a  pyramid  balanced  upon  its  point.  This  par- 
adoxical condition  does  not  exist  in  the  lower  animals  but  is  an  anom- 
aly in  the  animal  kingdom,  explained  by  the  upright  position  of  the 
human  species. 

When  we  consider  the  extensive  changes  of  volume,  form,  and  con- 


DISPLACEMENTS    OF   THE    UTERUS. 


417 


sistency  which  the  uterus  undergoes  at  each  pregnancy ;  the  alterations 
and  lesions  which  may  be  produced  by  parturition  on  the  adjacent 
organs,  ligaments,  muscles,  and  serous  membrane;  and  finally  the 
influence  which  efforts  of  all  sorts  may  exert  on  an  equilibrium  so 
unstable — we  are  surprised  that  uterine  displacements  are  not  more 
frequent. 

In  the  description  of  displacements  I  shall  treat  first  of   those 
which  are  produced  in  the  vertical  planes,  comprising  flexions  and 


Fig.  207. — Position  of  the  Utercs,  with  the  Bladder  Empty. 

versions,  for  which  I  reserve  the  name  deviations,  and  next  of  those 
which  follow  horizontal  planes,  i.e.,  elevation,  prolapse,  and  inversion. 
Classification. — The  displacements  in  the  vertical  planes  are  com- 
monly divided  into  versions  or  flexions  according  as  the  uterus  as  a 
whole  is  involved  or  only  the  body  flexed  on  the  cervix.  There 
may  be  therefore  ante-  and  retroflexion,  ante-  and  retroversion,  and 
latero-version  and  flexion.  The  latter  are  rare  in  the  simple  form,  but 
they  exist  in  combination  with  the  others.  When  the  uterus  is  dis- 
placed en  masse  backward  or  forward,  it  is  called  ante-  or  retro-posi- 
tion, two  words  which  have  only  a  descriptive  value. 

27 


418 


CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 


Historical  Review. — The  history  of  uterine  deviations  has  passed 
through  several  phases.  They  were  unknown  at  the  time,  before 
Recamier,  when  all  uterine  maladies  without  neoplasm  were  attributed 
to  prolapse;  by  Recamier  and  Lisfranc  they  were  relegated  to  the  sec- 
ond placed  by  the  prominence  which  these  authors  gave  to  ulceration; 
with  Velpeau,  on  the  contrary,  their  role  in  uterine  pathology  was 
much  exaggerated,2  This  latter  belief,  by  which  displacements  were 
made  the  chief  factor  in  gynaecology,  endured  till  (xosselin 3  produced 
a  reaction  in  favor  of  metritis.  The  science  becoming  more  analy- 
tic and  more  eclectic  at  the  same  time,  the  tendency  was  then  to  refer 


Fig.  208. — Position  of  the  Uterus,  with  the  Bladder  Half  Filled  (Waldeyer). 


each  disease  to  its  proper  place.  There  were  also  new  elements  intro- 
duced, up  to  that  time  almost  ignored,  which  resulted  from  patholog- 
ical conditions  of  the  adnexa. 

As  is  well  known,  displacement  by  itself  does  not  constitute  a  dis- 
ease, but  is  only  a  factor,  or  the  coefficient  in  a  morbid  complex  into 
which  the  deviation  enters  only  as  a  variable.  There  is  no  gynaecol- 
ogist who  has  not  seen  marked  displacement  in  women  who  presented 
no  symptom  of  disease,  and  certain  authors,  basing 4  their  statements 
on  this  fact,  have  not  hesitated  to  deny  the  pathological  importance 
of  deviations  completely.  They  go  from  the  one  excess  to  the  other. 
If  the  displacement  does  not  constitute  a  disease  by  itself,  it  creates 


DISPLACEMENTS   OF  THE   UTERUS.  419 

for  the  displaced  organ  a  peculiar  vulnerability  which  results  from 
alterations  in  the  circulation  produced  by  the  increase  of  the  venous 
tension  and  the  nutritive  changes  which  may  be  the  consequences  of 
this  condition;  it  favors  and  preserves  inflammation  of  the  uterus 
both  in  its  cavity  and  on  its  surface.5  Prolarjse  of  the  adnexa, 
moreover,  which  frequently  accompanied  the  inflammation  of  the 
uterus,  may  be  the  source  of  reflex  nervous  troubles  whose  impor- 
tance, especially  in  the  posterior  displacements,  should  not  be 
neglected.  And  the  adhesions  of  peri-salpingitis,  when  that  is 
added,  may  fix  the  uterus  in  the  vicious  position,  and  thus  render 
all  resulting  phenomena  the  more  distressing. 

From  the  preceding  it  is  evident  that  the  conception  of  uterine 
displacement,  which  was  formerly  so  simple  and  referred  to  one  point 
of  pathology  alone,  comprehends  for  us,  under  the  same  clinical  term, 
complex  elements  whose  treatment  should  be  considered  of  the  first 
importance,  even  before  that  of  the  actual  change  in  the  axis  of  the 
organ;  of  these  the  chief  are:  Metritis;  prolapse  of  the  adnexa,  either 
healthy  or  inflamed ;  peri-salpingitis ;  and,  especially  at  the  beginning 
of  the  treatment,  excessive  mobility  of  the  uterus  due  to  laxity  of 
the  ligaments. 

Displacements  Foewaed — Anteveesion. 

Pathology  and  Etiology. — The  normal  curvature  of  the  uterus 
coincides  fairly  well  with  the  curvilinear  axis  of  the  pelvis.  In  ante- 
version  this  curve  becomes  straight,  as  the  uterus  falls  forward  and 
the  organ  lies  just  behind  the  pubes  upon  the  bladder,  the  cervix 
presenting  directly  backward  (Fig.  209).  The  uterus  is  usually  some- 
what increased  in  size  by  a  certain  degree  of  metritis,  and  there  often 
exists  a  perimetritic  exudation  toward  one  of  the  poles  of  the  organ, 
sometimes  in  front  at  the  level  of  the  fundus,  sometimes  behind  at 
the  level  of  the  cervix,  which  tends  to  fasten  the  uterus  in  its  abnormal 
position. 

The  great  cause  of  anteversion  is  to  be  found  in  the  structural 
changes  which  occur  after  labor  and  abortion,  or  in  the  course  of  an 
abnormal  involution,  caused  by  a  slight  degree  of  infection.  The 
organ  takes  the  position  while  it  is  still  soft  and  yielding,  and 
maintains  it  because  its  normal  tonicity  fails  to  return.  Then  there 
are  adhesions  formed  and  the  uterus  becomes  fixed.  The  presence  of 
a  tumor  which  by  its  weight  causes  the  deviation  is  only  of  second- 
ary importance. 


420 


CLINICAL    AXD    OPERATIVE   GYNECOLOGY. 


[Anteversion  being  but  an  exaggeration  of  the  normal  position,  but 
rarely  causes  symptoms  or  needs  treatment  except  when  complicated 
by  parametritic  adhesions  or  contraction  of  the  utero-sacral  bands, 
which  markedly  limit  its  mobility.  In  a  limited  number  of  cases  of 
anteversion,  with  marked  relaxation  of  the  uterine  supports  and  "'  de- 
scent "  when  in  the  erect  position,  the  ring  rjessary  may  be  needed  as 
advised  below.] 

Symptoms. — The  uterine  syndroma  which  I  have  described  in 
discussing  metritis  reappears  here  in  all  its  characters.  The  rectal 
and  vesical  tenesmus  are  especially  noteworthy,  are  exaggerated  by  the 
pressure  of  the  uterine  body  and  neck,  but  yet  may  be   absent  or 


&J     1 


Fig.  209.— Anteversion. 


may  exist  with  simple  metritis.  The  nervous  reflexes  which  result  are 
due  to  the  uterine  mobility  and  the  entero-ptosis  which  it  causes  more 
than  to  the  mere  displacement,  which  is  demonstrated  by  the  effec- 
tiveness of  immobilization  by  means  of  the  pessary. 

Diagnosis. — The  diagnosis  is  easily  made  clear  by  bimanual  palpa- 
tion. The  finger  in  the  vagina  seeks  for  the  cervix  far  in  the  rear,  then, 
carried  forward,  feels  the  body  of  the-organ  through  the  anterior  cul-de- 
sac  and  may  follow  its  anterior  surface,  while  the  hand  placed  above 
the  pubes  examines  the  posterior,  placed  horizontally.  The  passage 
of  the  uterine  sound  is  usually  difficult  and  is  seldom  necessary.  It 
should  be  employed  only  when  there  is  any  doubt  as  to  the  nature  of 
the  tumor  felt  in  the  anterior  vaginal  pouch,  or  if  the  fundus  cannot 
be  differentiated  from  a  tumor  above  it,  such  as  a  fibroma  or  an  in- 
flammatory or  hemorrhagic  exudation.     Anteflexion  may  be  recog- 


DISPLACEMENTS   OF  THE   UTERUS.  421 

nized  by  the  curve  which  exists  at  the  junction  of  the  cervix  with  the 
body.  To  facilitate  the  passage  of  the  sound  into  the  cervix,  the 
anterior  lip  may  be  seized  with  a  tenaculum  and  drawn  gently  down- 
ward. Rectal  touch  in  such  cases  is  often  of  great  service  in  deter- 
mining whether  the  fundus  is  in  its  normal  position. 

Treatment. — As  it  is  the  metritis  which  causes  the  anteversion 
and  keeps  it  up,  we  must  address  our  efforts  in  the  first  place  to  that 
disease;  but  before  beginning  a  vigorous  treatment  of  the  uterine 
mucous  membrane,  we  must  assure  ourselves  that  there  is  no  acute 
inflammation  about  either  .uterus  or  tubes.  Should  there  be  acute 
perimetritis  or  salpingitis,  they  should  first  be  treated  by  appropriate 
means,  among  which  I  include  very  hot  vaginal  douches  [110°  F.  and 
for  twenty  to  thirty  minutes],  tampons  of  glycerin,  frequent  sitz  baths, 
and  vesication  over  the  hypogastrium ;  then  when  every  acute  symp- 
tom has  disappeared,  we  perform  currettage  and  follow  it  by  the  in- 
jection of  tincture  of  iodine  or  perchloride  of  iron  as  already  described 
(p.  197). 

There  is  no  need  here  to  replace  the  organ,  for  its  position  is  only 
an  exaggeration  of  the  normal  condition.  If  the  pain  persist  after 
the  metritis  has  been  cured  it  can  be  due  only  to  reflexes  which  take 
their  origin  from  the  relaxed  ligaments  and  the  entero-ptosis ;  it  is 
then  that  the  organ  should  be  immobilized  and  sustained,  and  this 
may  be  accomplished  either  through  the  abdominal  walls  or  by  way 
of  the  vagina. 

The  best  abdominal  supporter  in  the  case  of  forward  deviation  is 
that  which  carries  a  movable  cushion,  which  may  be  managed  by  a 
strap  or  a  channel  and  screw  after  its  application  above  the  pubes 
(see  Fig.  210). 

The  most  serviceable  form  of  pessary  in  anteversion  is  that  which 
I  term  "  the  indifferent,"  because  its  sole  function  is  to  distend  the 
vaginal  pouches  and  thus  immobilize  the  uterus  and  maintain  the 
cervix.  The  pessary  which  is  called  Dumontpallier's  in  France  and 
Mayer's  elsewhere,  in  the  form  of  an  elastic  ring,  is  the  best  example 
of  this  indifferent  class  of  instrument,  easy  to  apply,  withdraw,  and 
clean.  Special  forceps  have  been  invented  for  its  introduction  into 
the  vagina  without  pain  (Fig.  212),  but  with  a  little  experience  the 
same  result  is  obtained  by  holding  it  between  the  index  and  the 
thumb.  It  is  convenient  to  place  the  patient  in  the  lateral  or  genu- 
pectoral  position ;  then  it  is  necessary  merely  to  place  the  upper  part 
of  the  pessary  in  the  posterior  pouch,  push  the  anterior  portion  a 


422 


CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 


little  upward,  and  it  adapts  itself  automatically  to  the  parts.  Its  size 
should  be  determined  according  to  the  dimensions  of  the  vagina.  A 
pessary  which  does  not  overstretch  the  canal  or  cause  the  patient  in- 


Fig.  210.— 1,  Elastic  Abdominal  Girdle  (Payot).     2,  Girdle  Having 
a  Movable  Plate  with  Double  Motion. 


Fig.  211.— Dumontpallier's  or  Mayer's  Soft-Rubber  Ring  Pessary. 


Fig.  212. — Forceps  for  Intro- 
duction of  Ring  Pessary. 


convenience  may  be  left  in  place  two  or  three  months ;  it  does  not  inter- 
fere with  either  coitus  or  fecundation.  [While  a  well-fitting,  polished 
hard-rubber  pessary  may  often  be  left  in  place  this  length  of  time,  any 
soft-rubber  instrument  should  be  frequently  removed  and  cleansed, 


DISPLACEMENTS   OF  THE    UTERUS. 


423 


as  otherwise  they  soon  become  extremely  offensive.]  At  the  end  of 
that  time  it  should  be  taken  out  and  cleaned  in  carbolic  solution  and 
the  joatient  advised  to  go  without  it  for  a  few  days  to  see  whether 
it  is  still  necessary, 


Fig.  213.— Graily  Hewitt's  Cradle  Pessary  for  Anteversion. 


Many  special  forms  of  pessary  have  been  invented  and  advocated 
for  anteversion,  but  I  have  never  found  them  of  the  least  advantage. 
The  above  cut  shows  the  method  of  application  of  Hewitt's  pessary. 
The  use  of  Thomas'  form  will  be  more  easily  understood  when  we  con- 
sider the  figures  relating  to  Hodge's  pessary  for  retroversion,  for  it  is 
like  the  Hodge  but  with  the  difference  that  it  has  a  movable  piece 
shaped  like  a  horseshoe  which  passes  in  front  of  the  cervix  to  sustain 


Fig.  ai4.— Thomas1  Anteversion  Pessary. 


Fig.  215.— Galabin's  Anteversion  Pessaet. 


the  uterine  body.     Galabin's  model  has  its  anterior  portion  much 
thickened  for  the  same  purpose. 

As  regards  general  treatment,  the  angemia  and  the  nervous  excita- 
bility should  be  controlled.  Preparations  of  iron  and  quinine,  and 
hydrotherapy  will  be  beneficial  in  many  cases. 

Anteflexion. 

Pathology  and  Etiology. — Anteflexion  is  an  exaggeration  of  the 
normal  forward  curvature  of  the  uterus.  Before  it  was  well  under- 
stood it  was  frequently  the  case  that  a  uterus  in  perfect  position  was 


424  CLINICAL   A15TD    OPEEATITE   GYNAECOLOGY. 

taken  for  one  in  a  state  of  pathological  deviation.  It  is  difficnlt  to 
draw  a  clear  distinction  between  the  physiological  and  the  abnormal 
positions ;  but  it  might  be  said  that  the  abnormal  begins  when  the 
examining  finger  perceives  the  angle  as  a  sharp  bend  in  the  axis  of 
the  organ. 

[Schnltze  holds  that  this  distinction  is  not  an  invariable  one.  He 
states  that,  as  contrasted  with  the  great  mutability  of  normal  anteflex- 
ion, stability  is  the  characteristic  most  typical  of  pathological.  Patho- 
logical anteflexion  is  then  that  position  in  which  the  uterus  lies  with 


Fig.  216.— Various  Forms  of  the  Cervix,  Natural  Size  (Schultze).  a,  Fully  developed  normal 
cervix,  normally  inserted  iuto  the  vaginal  vault;  6,  an  approximation  to  the  condition  in  childhood  often 
found  in  virgins  and  usually  accompanied  by  flexion;  c,  cervix  and  mode  of  insertion  normal  during 
childhood;  when  found  in  the  adult  it  is  nearly  invariably  associated  with  sharp  flexion. 

its  fundus  permanently  flexed  over  its  anterior  surface  and  more  than 
normally  stabile.] 

T.  G-aillard  Thomas  distinguishes  three  varieties : 

1.  Corporeal  flexion,  where  the  body  is  bent  upon  the  cervix  which 
is  normally  placed;  this  is  the  usual  type. 

2.  Cervical  flexion,  where  the  cervix  is  bent  upon  the  body. 

3.  Cervico-corporeal,  where  the  segments  of  the  organ  are  bent  the 
one  upon  the  other. 

Etiologically  there  are  two  forms,  the  congenital  and  the  acquired. 

In  the  foetus  and  in  early  infancy  the  cervix  is  relatively  much 
developed  while  the  body  is  still  small,  and  there  is  an  exaggerated 
curve  between  them;  if  at  the  time  of  puberty  the  growth  of  the 
uterus  is  irregular  and  the  anterior  wall  is  retarded  in  its  develop- 
ment while  the  posterior  increases  in  size,  the  congenital  form  of  ante- 
flexion manifests  itself.  As  a  second  mark  of  arrested  growth,  the 
cervix  may  be  very  long  and  conical  (Fig.  217),  with  the  vaginal  por- 
tion tapering  and  the  external  os  very  narrow.  At  other  times  atro- 
phy of  the  anterior  lip  may  be  pronounced  and  thus  furnish  an 
indication  of  the  condition  of  the  corresponding  uterine  wall.     This 


DISPLACEMENTS    OF   THE   UTERUS. 


425 


congenital  anteflexion  lias  been  observed  with  hypoplasia  of  all  the 
genital  organs  and  a  narrow  pelvis. 

The  congenital  forms  do  not  present  so  acute  an  angle  of  flexion 

l\ 


Fig.  217.— Anteflexion  of  Infantile  Origin.    The  angle  is  anute  and  the  fundus  globular. 

as  the  acquired  forms,  but  corresiDond  generally  to  the  first  two  varie- 
ties of  Thomas. 

The  anteflexion  may  be  acquired  at  the  time  of  the  establishment 
of  puberty  if,  when  the  uterus  is  engorged  and  softened  during  the 


Fig.  218. — Very  Acute  Anteflexion  with  Hypertrophy  of  the  Vaginal  Portion  of  the  Cervix. 

first  menstrual  periods,  the  hygiene  of  the  young  woman  is  improper. 
Any  overstrain  or  great  fatigue,  masturbation,  and  all  the  causes  of 
virginal  metritis  may  here  play  their  part  in  developing  both  an  in- 
flammation and  a  deviation.     It  is  readily  seen  that  the  general  soft- 


426 


CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 


ness  of  the  organ  permits  it  to  bend  at  the  isthmns  as  npon  a  hinge 
and  to  become  flexed  to  the  side  or  to  increase  its  infantile  forward 
curve.  Cases  have  been  observed  where  a  fall  was  the  starting-point 
of  this  condition. 

Metritis  of  puerperal  origin  may  be  counted  among  the  causes  of  ac- 
quired anteflexion,  though  it  more  commonly  produces  a  retroflexion. 
It  has  been  attributed  with  much  reason  to  absence  of  sufficient  involu- 
tion of  the  posterior  wall  after  labor  and  abortion,6  and  this  may  be 
due  to  the  persistence  of  portions  of  the  membranes  or  placenta 
causing  a  very  intense  local  infection  at  the  place  of  their  adhesion. 
Schultze,7  after  E.  Martin,  has  attributed  great  importance  to  para- 
metritis situated  posteriorly,  involving  the  utero-sacral  ligaments  and 


Fig.  219.— Anteflexion  prom  Contraction  of  the  Utero-Sacral  Ligaments. 


causing  their  contraction  (Fig.  219).  He  also  asserts  that'in  such  cases 
the  cervix  is  placed  much  higher  than  normal  in  the  pelvis,  and  the 
vagina  thus  undergoes  elongation.  The  origin  of  the  posterior  para- 
metritis he  finds  in  puerperal  or  gonorrhceal  infection. 

I  am  of  the  opinion  that  this  is  most  frequently  due  to  peri-salpin- 
gitis  about  the  diseased  adnexa.  The  adhesions  which  result  and 
which  fix  the  cervix  strongly  from  behind  cause  the  uterus  to  fall 
forward  and  flex  it  at  the  isthmus,  which  is  weakened  by  the  accom- 
panying metritis,  while  the  cervix,  hypertrophied  and  sclerosed  by 
an  old  inflammation,  remains  rigid  (Fig.  220).  The  subvaginal  elonga- 
tion of  the  cervix  results  in  inveterate  catarrh,  which  often  coexists 
with  anteflexion,  as  has  been  well  described  by  A.  Martin ;  this  author 
considers  the  congenital  lesions  of  but  little  importance.8 


DISPLACEMENTS    OF   THE    UTERUS. 


427 


Symptoms. — Congenital  anteflexion  is  accompanied  by  amenor- 
rhea, or  delay  in  the  appearance  of  the  menses,  when  it  coincides 
with  an  infantile  condition  of  all  the  genital  organs.  If  the  periods  be- 
gin at  the  normal  time,  they  are  apt  to  be  at  long  intervals  and  irregu- 
lar. At  other  times  with  a  normal  flow  of  blood  there  appear  the  symp- 
toms of  dysmenorrhcea.  Violent  pains  in  the  loins  occur  while  the 
blood  distends  the  uterus  above  the  point  of  flexion,  then,  suddenly, 
the  obstacle  is  overcome  and  the  blood  is  expelled  in  a  clotted  flow, 
which  may  have  a  very  strong  odor,  due  to  its  long  stagnation.  The 
mechanical  theory  of  the  pain  of  dysmenorrhcea  depending  upon  ante- 
flexion has  been  generally  received  since  it  was  made  known  by  Simp- 


Fig.  220. — Anteflexion  Combined  with  Retro-Position  and  Posterior  Adhesions. 


son  and  Sims.  It  is  not,  however,  accepted  by  Fritsch,  who  explains 
the  pain  as  due  to  irritation  of  the  nerves  from  congestion  by  the 
abnormal  vascular  tension  produced  by  curvature  of  the  vessels  at 
the  point  of  the  flexion.  It  is  difficult  not  to  attribute  great  impor- 
tance to  the  obstacle,  in  view  of  the  paroxysmal  character  of  both 
pains  and  discharge.  We  may  also  ask  whether  the  posterior  peri- 
metritis noted  by  Schultze  is  not  as  often  the  result  of  the  anteflexion 
as  its  cause,  when  every  month  there  are  a  few  drops  of  blood  forced 
through  the  tubes  into  Douglas'  pouch,  producing  thus  a  kind  of 
miniature  and  periodic  hsematocele.  Thus  we  might  explain  the 
acute  and  febrile  phenomena  with  which  these  crises  of  dysmenorrhea 
sometimes  terminate. 

These  patients  present  all  the  symptoms  of  the  uterine  syndroma. 


428 


CLINICAL   AND   OPEEATIVE   GYNAECOLOGY. 


The  dysuria  is  ordinarily  very  marked  and  the  reflex  nervous  symp- 
toms are  bitterly  complained  of. 

Pain  often  occurs  in  sexual  intecrourse,  the  dyspareunia  of  Barnes. 
Sterility  is  the  rule,  and  should  conception  take  place,  abortion  is 
probable. 

Diagnosis. — If  the  case  is  one  of  the  frequent  acquired  anteflex- 
ions,  the  so-called  corporeal,  the  finger  feels  the  fundus  in  the  anterior 
vaginal  pouch,  curved  like  a  pistol  handle  and  almost  on  the  same 
plane  as  the  cervix.  By  pressing  the  organ  down  in  bimanual  palpa- 
tion, the  body  of  it  is  rendered  accessible  and  the  finger  can  appreci- 
ate its  curve  and  angle  of  flexion,  while  the  cervix  is  found  in  the 
normal  axis. 


Fig.  221.— Anteflexion  Simulated  by  a  Fibroma  in  the  Anterior  Uterine  Wall. 

In  the  cervical  variety  of  the  affection  the  cervix  is,  on  the  con- 
trary, oblique  from  above  downward  and  from  before  backward;  by 
touch  alone  we  might  then  think  of  retroversion,  but  bimanual  palpa- 
tion discovers  the  fundus  in  the  normal  situation. 

In  the  cervico-corporeal  variety  the  direction  of  the  cervix  is  the 
same  as  in  the  preceding  form,  but  the  fundus  is  also  curved  and 
hidden  behind  the  pubes;  by  exploring  the  anterior  cul-de-sac  in 
front  of  the  cervix  it  may  be  felt.  At  times,  when  the  uterus  is 
thus  rolled  on  itself,  there  is  nothing  to  be  felt  but  the  angle  of 
flexion ;  and  above  it  a  rounded  mass  which  might  very  easily  be  taken 
for  a  fibroma  or  an  inflammatory  exudation.  The  opposite  mistake 
has  also  been  made  (Fig.  221).  The  uterine  sound  is  of  great  service 
in  these  cases.  Its  introduction  may  be  rendered  easy  by  seizing  the 
cervix  with  tenaculum  forceps  and  drawing  it  down  and  back,  when 


DISPLACEMENTS    OF   THE   UTERUS.  429 

the  sound,  properly  curved,  is  passed  in  with  great  care  and  gentle- 
ness in  the  supposed  direction  of  the  uterine  cavity,  while  one  finger 
presses  on  the  fundus  through  the  anterior  vaginal  pouch  to- straighten 
it  a  little.  When  the  sound  is  in  the  uterus  the  organ  may  be 
restored  to  its  normal  shape  by  merely  carrying  the  handle  of  the 
instrument  forward.  Then  the  two  surfaces  of  the  organ  may  be  ex- 
amined by  rectal  touch  and  bimanual  palpation,  to  discover  the  pres- 
ence of  any  tumor  which  may  coexist  and  to  estimate  the  uterine 
mobility.  To  avoid  all  danger  of  interrupting  a,  beginning  preg- 
nancy, this  examination  should  be  made  only  shortly  after  a  menstrual 
period. 

A  calculus  in  the  bladder,  pressing  upon  the  anterior  cul-de-sac, 
could  only  be  mistaken  for  anteflexion  when  the  examination  of  the 
uterus  and  vesical  catheterism  were  not  combined. 

Treatment. — The  indications  are  to  relieve  symptoms,  to  cure  the 
pathological  conditions  of  the  mucosa,  to  induce  a  return  to  the  normal 
in  the  muscular  tissue  and  to  restore  the  normal  uterine  position. 
Acquired  anteflexion  causes  but  little  disturbance  except  when  there 
is  coincident  inflammation  or  when  it  presses  upon  the  bladder  or  with 
a  very  movable  uterus.  Relief  may  be  obtained  by  either  a  girdle  or 
a  pessary  without  the  need  of  previous  reduction  {vide  supra, 
Ante  version). 

The  treatment  should  be  directed  chiefly  against  the  coexisting 
metritis.  In  simple  cases  curetting  followed  by  iodine  injections  will 
be  found  sufficient.  With  marked  cervical  hypertrophy  Schroder's 
biconical  amputation  or  excision  of.  the  mucous  membrane  will  be 
required.  This  causes  a  rapid  and  progressive  involution  of  the 
hypertrophied  cervix,  which  much  exceeds  the  immediate  results 
obtained  by  the  bistoury,  and  which  with  the  amelioration  of  the 
metritis  causes  the  disappearance  of  the  morbid  symptoms  which  are 
attributable  to  the  deviation.  The  displacement  corrects  itself  little 
by  little.  It  seem§  probable  to  me  that  the  good  effects  of  Sims' 
"  sagittal  discission  "  (Fig.  222),  which  has  enjoyed  such  favor  and  been 
so  much  abused,  should  be  referred  to  the  indirect  action  of  the  opera- 
tion upon  the  involution  of  the  uterus  and  its  influence  on  the  metritis, 
rather  than  to  the  mere  re-establishment  of  the  normal  calibre  of  the 
cervix. 

Congenital  anteflexion  claims  our  interference  only  because  of  the 
very  painful  dysmenorrhea  or  the  sterility  which  it  causes.  If  we 
decide  to  straighten  and  dilate  the  organ,  as  has  been  recommended, 


430  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

it  is  well  to  precede  every  attempt  at  straightening  by  the  use  of  lami- 
naria  tents,  after  determining  the  extent  and  direction  of  the  uterine 
cavity  by  the  sound.  The  laminaria  tents,  treated  with  iodoform  and 
sufficiently  thin,  are  supple  enough  to  permit  a  good  deal  of  curvature. 
It  is  useless  to  attempt  too  great  a  dilatation;  the  principal  office 
of  the  tents  is  to  soften  the  tissues  and  make  them  more  supple  in 
view  of  the  final  restoration  of  the  form  of  the  organ.  This  is  begun 
with  the  dilatation  itself.  After  dilating,  enlarging,  and  somewhat 
correcting  the  axis  by  the  use  of  a  few  tents,  we  may  continue  by 
passing  Hegar's  bougies  once  or  twice  a  week,  aiding  the  manoeuvre 
by  fixing  the  cervix  with  tenaculum  forceps  and  by  pressure  on  the 
fundus  by  the  finger  in  the  anterior  vaginal  pouch ;  the  process  should 
be  completed  with  sizes  No.  10  or  12.  Eapidly  straightening  the 
uterus  with  a  sound,  returning  it  to  its  position  by  a  ''''tour  de 


Fig.  2  .'2. —Sagittal  Discission  of  the  Cervix  in  Cervical  Anteflexion  (Sims),  a,  &,  C,  portion  of  the 
cervix  divided  by  the  scissors  ;  c,  a,  d,  triangular  portion  which  escapes  the  scissors  and  which  is 
divided  by  the  probe-pointed  bistoury ;  e,  /,  supravaginal  portion  of  the  cervix  where  the  flexion  occurs. 

maitre,"  which  temporarily  carries  the  organ  backward,  is  here  al- 
ways out  of  place. 

Since  the  case  is  almost  always  one  of  incomplete  development,  the 
progressive  dilatation  and  the  frequent  passage  of  sounds  will  pro- 
duce a  fluxion  to  the  part  and  an  increase  in  its  nutritive  activity, 
which  are  probably  the  chief  advantages  of  the  method. 

In  addition  to  the  pessaries  which  I  have  described,  which  are 
applicable  to  both  anteflexion  and  ante  version  alike,  special  forms 
have  been  invented  for  anteflexion.  That  of  Fancourt  Barnes  is  a 
combination  of  the  Hodge  model  with  the  Hewitt.  Thomas  has  in- 
vented a  complicated  form  composed  of  a  Smith  pessary  supporting 
a  cup  with  an  intra-uterine  stem.  I  much  prefer  abdominal  girdles 
to  vaginal  pessaries  in  both  anteversion  and  anteflexion,  but  among 
the  latter  I  consider  Dumontjjallier's  ring  sufficient. 

The  stem,  or  intra-uterine,  pessary 9  so  warmly  advocated  in  Eng- 


DISPLACEMENTS    OF  THE   UTERUS. 


431 


land  by  Simpson  and  in  France  by  Valleix,10  which  has  caused  so 
many  accidents  before  the  days  of  antiseptic  surgery,  should  be  em- 
ployed only  in  exceptional  cases.11  When  the  patient  is  a  weak 
and  timid  young  woman  who  is  very  nervous  and  for  whom  the  re- 
peated manoeuvres  of  progressive  dilatation  would  be  torture  or  at 
least  present  a  real  difficulty  every  time,  we  are  authorized  to  leave 
an  agent  within  the  uterus  which  shall  gradually  straighten  and 
dilate  it.  The  older  forms  of  pessary  had  a  stem  which  was  per- 
fectly straight,  which  is  erroneous,  as  the  normal  uterus  has  an  an- 
terior curvature.  They  were  often  composed  of  two  metals,  copper 
and  zinc,  whose  galvanic  action  was  thought  to  aid  the  salutary  action 
of  the  dilatation.  Fehling  constructed  a  far  more  rational  instrument 
consisting  of  a  tube  of  thick  glass,  fenestrated,  provided  with  a  bell 
mouth,  and  slightly  curved;   this  curve  could   be  altered  by  heat. 


Fig.  223. — Stem  Pessaries,    a  and  6,  Common  forms;  c,  Fehling's. 

This  tube  was  to  be  filled  with  powdered  iodoform  and  introduced 
into  the  uterine  cavity,  with  care  that  the  tube  be  about  one-half  cen- 
timetre shorter  than  the  canal,  previously  measured.  The  patient  is 
kept  in  bed  and  under  observation  for  eight  days ;  then  she  is  allowed 
to  rise,  but  the  stem  is  not  removed,  according  to  this  author,  before 
eight  or  ten  months.12  It  is  kept  in  place  by  the  projection  of  the 
mucous  membrane  into  the  fenestras  of  the  tube,  and,  being  light,  has 
but  little  tendency  to  fall  out  (Fig.  223,  c).  I  think  that  this  delay 
of  eight  months  is  too  long,  and  that  the  good  effects  should  be  pro- 
duced within  one  or  two.     [Yide  Dysmenorrhcea.] 

The  chief  cause  of  the  dysmenorrhcea  in  congenital  anteflexion  is 
in  the  conical  cervix  with  its  stenotic  external  os.  To  relieve  this 
stenosis,  crucial  incision  with  the  bistoury  has  been  practised  for  a 
long  time.  Simpson's  metrotome,  Collin's  hysterotome,  or  Kiichen- 
meister's  scissors  may  be  employed. 


432  CLINICAL   A1STD   OPERATIVE   GYNAECOLOGY. 

The  results  so  obtained  are  not  permanent,  for  the  cicatrization  re- 
establishes the  original  conditions;  a  stomatoplastic  operation  by 
biconical  amputation  of  the  cervix  is  far  preferable.13  (Vide  Cervical 
stenosis). 

The  operation  of  discission  in  cervical  anteflexion  is  sometimes 
performed  for  the  relief  of  sterility.  Marion  Sims  (Fig.  222)  incised 
the  posterior  lip  of  the  cervix  with  his  short  and  curved  bistoury. 
Emmet  practised  the  same  incision  with  elbowed  scissors,  which  are 


Fig.  224.— Collin's  Hysterotomy. 

preferable;  he  straightened  the  canal  by  making  an  incision  on  its 
anterior  face  with  a  short  tenotome  a  certain  depth  into  the  tissues 
and  kept  the  cut  open  by  means  of  a  glass  tube.  He  thus  removed 
a  triangular  piece  or  the  whole  of  the  posterior  lip.  More  compli- 
cated plastic  operations  have  been  proposed,  like  Kiistner's  [or  Dud- 
ley's 14J,  but  I  reject  them  all.  If  there  is  any  deformity  of  the  cervix, 
amputation  of  the  part  is  preferable  (according  to  the  rules  given 
under  Metritis),  taking  care  to  leave  a  sufficiently  large  os. 

BIBLIOGRAPHY. 

1.  Knowledge  of  this  normal  antecurvature  is  of  recent  date  and  is  due  to 
Velpeau  and  his  pupils.  Velpeau:  Bull,  de  l'Acad.  de  M6decine,  1849-50,  t.  xv., 
p.  72.  Piachaud:  Les  Deviations  de  l'Uterus.  These  de  Paris,  1852.  Boullard: 
Quelques  Mots  sur  l'Uterus.     These  de  Paris,  1853. 

2.  Herves  de  Ch^goin:  De  quelq.  Deplacem.  de  la  Matr.  et  des  Pess.,  etc. 
Memoir,  de  l'Acad.  de  MeU,  1833,  p.  139,  t.  ii. 

3.  Gosselin:  Arch.  Gen.  de  M6d.,  t.  ii.,  p.  129,  1843. 

4.  J.  M.  Duncan:  Clinical  Lectures  on  the  Diseases  of  Women,  3d  edit.,  London, 
1886,  Lessons  44  and  45.'  Vedeler:  Arch.  f.  Gyn.,  Bd.  xxviii.,  Hft.  2.  The  latter 
author  maintains  that  retroflexion  has  only  a  physiological  interest.  Among  313 
cases,  40$  had  no  morbid  symptoms  and  among  60  who  were  ill,  it  was  with  troubles 
due  to  nervous  conditions,  gonorrhoea,  etc. 

5.  M.  P.  Jacobi:  Notes  on  Uter.  Vers,  and  Flex.,  Amer.  Jour.  Obst.,  vol.  xxi., 
p.  225.  This  article  contains  considerations  of  interest,  although  a  little  too  the- 
oretic, on  the  pathogeny  of  displacement  and  the  pathological  physiology  of  the 
symptoms  caused. 

6.  E.  Martin,  Sr. :   Die  Neigung.  und  Beug.  des  Uter.,  Berlin,  1870,  p.  144. 

7.  Schultze:  Trait6  des  Deviat.  Uter.,  trans,  of  Herrgott,  Paris,  1884,  p.  210. 
Martin:  Loc.  cit.,  p.  123. 

8.  A.  Martin:   Traits'  Clin,  des  Mai.  des  Fern.,  French  Ed.,  1889,  p.  93. 

9.  Winckel:   Die  Behand.  der  Flex,  des  Uter.  mit  Intra-uter.  Elevatoren,  1872. 

10.  On  this  historical  point  see,  Rochard:  Hist,  de  la  Chirurg.  Franc,  au  xix. 
Steele,  1885,  p.  834, 


DISPLACEMENTS    OF  THE   UTERUS.  433 

11.  This  treatment  has  still  its  warm  partisans.     Gr.  Thomas:  New  York  Med. 
Jour.,  Dec.,  1888. 

12.  Fritsch:   Die  Krank.  der  Frauen,  3d  edit.,  1886,  p.  244. 

13.  A.  Martin:  Path,  und  Ther.  der  Prauenk.,  p.  85. 

14.  E.  G.  Dudley:  A  Plastic  Operation  Designed  to  Straighten  the  Anteflexed 
Uterus.     Am.  Jour.  Obst.,  p.  142,  1891. 


.      OHAPTEE  XVIII. 

DISPLACEMENTS   OP  THE  UTEBUS— Continued. 

Posterior  Deviations. 

Displacement  of  the  uterus  backward  is  far  more  frequent  than 
any  other  variety.  Sanger,1  among  700  gynaecological  patients,  found 
108  cases  of  retro-deviation,  or  15.14$.  Winckel  obtained  19.10$,  and 
Lohlein  17  or  18$.2 

I.  Retroversion. 

Pathology;  Etiology. — Every  time  that  the  bladder  empties  itself, 
the  uterus  is  placed  physiologically  in  a  temporary  position  of  retro- 
version.   The  tonicity  of  the  broad,  round,  and  utero-sacral  ligaments, 


Fig.  295. — Retroversion  with  Posterior  Adhesions  of  Large  Extent. 

which,  it  must  not  be  forgotten,  contain  much  muscular  tissue,  ordi- 
narily sustain  the  uterus  in  its  normal  position;  but  when  it  has  be- 
come inoreased  in  weight  by  inflammation  and  especially  by  retarded 
involution  after  parturition,  the  ligaments  themselves  undergo"  a 
relaxation,  while  the  uterus  is  rendered  turgid  by  metritis,  and  the 
abnormal  position  may  become  permanent  under  the  influence  of  pro- 
longed dorsal  decubitus. 


DISPLACEMENTS    OF   THE   UTERUS.  435 

Then  the  uterus  often  becomes  fixed  in  the  new  and  abnormal  sit- 
uation, by  adhesions,  the  result  of  a  local  pelvic  peritonitis  originat- 
ing from  an  inflamed  tube  which  may  be  the  antecedent  and  chief 
cause  of  the  whole  disturbance.  A  sudden  effort  or  a  fall  is  often  the 
determining  cause  of  the  deviation;3  retroversion  is  not  so  common 
as  retroflexion. 

Symptoms. — When  the  displacement  has  occurred  suddenly,  it  is 
often  accompanied  by  acute  pain  and  various  nervous  phenomena; 
when  it  is  acquired  slowly,  its  symptoms  are  often  not  to  be  distin- 
guished from  those  of  a  metritis  or  of  a  circumscribed  perimetritis 
which  may  have  preceded  it,  and  with  these  we  find  the  uterine  syn- 
droma.  Sterility  is  the  rule.  Vesical  and  rectal  tenesmus  may  either 
be  very  marked  or  absent  altogether.  Palpation  and  touch  recognize 
the  position  of  the  cervix  forward  and  that  of  the  fundus  posteriorly 
toward  the  concavity  of  the  sacrum,  where  it  is  more  or  less  immobil- 
ized. The  two  segments  of  the  uterus  are  found  in  the  same  straight 
line. 

Diagnosis. — Bimanual  palpation  with  rectal  touch,  and  the  use  of 
the  uterine  sound  if  necessary,  are  the  means  by  which  this  form  of 
displacement  may  be  recognized.  The  distinction  from  retroflexion  is 
found  in  the  fact  that  there  is  no  angle  in  the  organ  between  cervix 
and  fundus.  It  should  not  be  confounded  with  fibroma  of  the  pos- 
terior wall,  with  a  retro-uterine  hematocele,  tumor  of  the  ovary  or 
tube  prolapsed  into  the  cul-de-sac  of  Douglas,  with  a  focus  of  para- 
metritis or  with  a  scybalous  accumulation.  Almost  all  cases  where 
any  doubt  could  exist  are  easily  made  clear  by  the  uterine  sound  com- 
bined with  other  means  of  exploration ;  this  instrument  being  espe- 
cially useful  where  we  must  differentiate  the  condition  from  anterior 
cervico-corporeal  displacement,  which,  in  view  of  the  direction  of 
its  antero-posterior  axis,  is  almost  necessarily  a  source  of  error  if  we 
confine  our  examination  to  touching  the  cervix  alone. 

Treatment. — This  is  similar  to  that  for  retroflexion. 


II.  Retroflexion. 

Pathology;  Miology.-Coia.tmYj  to  the  forward  deviations,  retro- 
flexion seldom  exists  from  childhood  or  puberty,  although  it  may 
follow  virginal  metritis,  habitual  constipation,  and  masturbation 
(Fritsch).  In  the  immense  majority  of  cases  the  retroflexion  succeeds 
to  a  metritis  of  puerperal  origin ;  the  subinvolution  of  the  anterior 


436 


CLINICAL    AND    OPERATIVE   GYNECOLOGY. 


face  where  the  placenta  is  inserted  plays  here,  according  to  E.  Martin, 
a  role  similar  to  that  which  I  have  indicated  for  anteflexion. 

Considerable  importance  must  also  be  attributed  to  the  weight  of  the 
congested  organ,  and  to  relaxation  of  the  broad  and  round  ligaments, 
which  cease  to  hold  the  uterus  in  place  anteriorly,  while  the  cervix  re- 
mains fixed  by  the  more  resistant  utero-sacral  ligaments.  The  flaccid- 
ity  of  its  own  supports  thus  allows  the  uterus  to  bend  backward  at 
^he  level  of  the  isthmus,  impelled  by  the  weight  and  pressure  of  the 


Fig.  226.— Retroflexion  op  the  Uterus  from  Subinvolution  of  the  Anterior  Wall,  on  Which  may  be 
Seen  the  Site  of  Placental  Insertion  (E.  Martin,  Sr.). 


intestines.  Retroflexion  has  been  observed  to  follow  simple  retro- 
version and  even  anteversion ;  in  the  latter  case  this  is  possible  when 
the  seat  of  the  flexion  remains  soft  and  movable  like  a  hinge.  The 
cervix  is  directed  downward  and  forward,  ordinarily  approaching  the 
vulva,  for  it  is  usually  a  little  lowered.  The  external  os  is  somewhat 
patent  and  its  lips  are  swollen,  owing  to  the  disturbance  of  the  venous 
circulation  which  results  from  the  curvature  of  the  vessels.  It  must 
not  be  forgotten  that  the  displacement  almost  always  happens  in 
a  woman  who  has  had  at  some  time  metritis  of  puerperal  origin. 


DISPLACEMENTS   OF   THE   UTERUS. 


437 


Fig.  227. — Extreme  Retroflexion  op  the 
Uterus. 


The  body  of  the  organ  occupies  the  pouch  of  Douglas.  On  one  or  the 
other  of  its  walls  there  has  been  found  a  marked  thinning,  anteriorly 
by  Ruge,  posteriorly  by  Fritsch. 

Adhesions  are  often  present,  either  perimetritic  from  exudation 
into  Douglas'  pouch,  or  parametritic  from  similar  conditions  about 
the  utero-sacral  ligaments.  According 
to  the  opinion  of  Schultze,  relaxation 
of  the  folds  or  ligaments  of  Douglas 
under  the  influence  of  posterior  para- 
metritis play  a  great  part  in  the  produc- 
tion of  all  the  uterine  displacements.4 
In  order  to  comprehend  the  produc- 
tion of  retroflexion,  we  must  suppose 
that  during  a  first  stage  of  acute  in- 
flammation the  ligaments  preserve  all 
their  resilience  in  such  a  way  that  the 
cervix  becomes  fixed ;  soon  after,  in  the 
stage  where  the  exudation  retreats,  the  denutrition  of  the  ligaments 
causes  their  flaccidity ;  then,  according  as  the  cervix  has  resisted  or 
become  flexed  in  the  first  stage,  we  have  a  retroversion  or  flexion.  In 
other  words,  version  presupposes  alteration  in  the  ligaments ;  flexion, 

an  altered  condition  of  both 
ligaments  and  uterine  paren- 
mar /  i   i  chyma  together. 

The  peritoneal  adhesions 
fix  the  uterus  to  the  bottom 
of  the  recto- uterine  pouch, 
by  bands  often  loose,  fila- 
mentous, and  easily  torn. 
At  other  times  they  are  fu- 
nicular, lamellated,  and  firm. 
The  ovaries  and  tubes  are 
often  drawn  by  the  devia- 
tion into  the  cul-de-sac.     It 

Fig.  228.— Retroflexion  of  the  Uterus  in  a  Nullipara. 
The  cervix  is  movable,  the  os  has  preserved  nearly  its  normal     is    probable    that    B.    part   of 

the  nervous  reflexes,  often 
grave  even  to  the  production  of  paraplegia,  which  have  been  noted 
in  cases  of  retroflexion,  are  due  to  the  dragging  upon  the  nerves, 
and  not  to  the  problematical  compression  of  the  sacral  plexus. 

Salpingitis  often  coexists,  and  is  the  rule  in  the  irreducible  cases, 


438 


CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 


the  fact  that  the  organ  cannot  be  reduced  very  frequently  depend- 
ing upon  the  presence  of  adhesions  between  the  adnexa  and  the  wall 
of  the  pelvis.  Exacerbations  of  the  salpingitis  are  the  cause  of  these 
adhesions,  and  also  of  the  hard,  often  painful  nodules  that  so  rapidly 
appear  and  disappear  about  the  lateral  and  posterior  surfaces  of  the 
retroflexed  organ.5 

Symptoms.— The  uterine  syndroma  is  present,  the  reflex  nervous 
phenomena  are  very  well  marked,  and  there  is  sterility.  Constipation, 
with  or  without  tenesmus,  is  peculiarly  obstinate,  and  Barnes  attrib- 
utes to  this  the  coprsemia  which  so  often  debilitates  the  rjatient. 


Fig.  229.— Retroflexion  of  the  Uterus,  Very  Pronounced.  Compression  of  the  rectum,  whose 
lumen  is  effaced ;  hypertrophy  of  the  cervix;  atrophy  of  the  angle  of  flexion;  thickening  of  the  posterior 
lip;  thinning  of  the  anterior  lip  which  is  hidden  in  the  bottom  of  the  cul-de-sac. 


The  nervous  reflexes  appear  most  often  as  difficulty  in  walking 
markedly  out  of  proportion  with  that  caused  by  simple  muscular 
fatigue  and  simulating  paraplegia,  as  multiple  neuralgias,  hysteri- 
form  excitability,  fitful  cough,  dyspepsia,  etc.  Schroder  has  ob- 
served chorea ; 6  Chrobak,  very  intense  asthma ; 7  Kehrer,  aphonia ; 8 
Sielki,  hystero-epilepsy ; 9  Kidderlen,  incessant  vomiting.10  Simple 
straightening  of  the  uterus  has  caused  all  these  symptoms  to  disap- 
pear rapidly. 

Sterility  is  usually  the  sequence  of  retroflexion,  though  at  any 
time  fecundation  may  take  place  and  the  uterus  return  to  its  proper 
position.  If  it  remains  flexed  and  incarcerates  the  foetus  in  the  lower 
pelvis,  it  produces  serious  compression  symptoms  or  abortion.      If 


DISPLACEMENTS   OP  THE   UTEKUS.  439 

involution  proceeds  under  the  most  favorable  conditions  after  labor, 
the  uterus  may  correct  its  own  malposition  spontaneously.  That  preg- 
nancy in  such  cases  may  be  a  valuable  therapeutic  measure  cannot  be 
denied,  and  yet  its  importance  has  been  much  overestimated. 

Certain  authors  describe  a  post-puerperal  retroflexion  where  the 
displacement  occurs  immediately  after  confinement.  This  is  often  only 
one  of  the  symptoms  of  a  post-puerperal  metritis  with  retarded  involu- 
tion, and  disappears  with  the  latter  under  appropriate  treatment. 

Diagnosis. — The  tumor,  occupying  the  posterior  cul-de-sac  may, 
by  means  of  bimanual  palpation,  be  easily  recognized  as  the  fundus 
from  the  absence  of  resistance  in  the  anterior  pouch  where  the  organ 
is  normally  pjlaced,  and  the  possibility  of  feeling  the  angle  of  junction 
between  the  cervix  and  the  fundus.  Rectal  touch  is  here  often  indis- 
pensable. Exploration  with  the  sound  removes  the  last  doubts ;  it 
should  be  curved  to  suit  the  axis  of  the  uterus,  and  the  cervix  seized 
with  tenaculum  forceps  and  drawn  downward.  Further  details  of 
diagnosis  will  be  found  under  the  head  of  retroversion,  to  which  I 
refer  (see  page  435). 

It  is  necessary  to  clearly  determine  the  degree  of  mobility  of  the 
uterus  before  entering  upon  any  treatment,  and  from  this  point  of 
viewTrelat11  divides  retroflexions  into  three  classes — (1)  reducible; 
(2)  resistant;  (3)  adherent.  These  different  grades  may  be  appre- 
ciated after  efforts  of  reduction,  either  by  the  bimanual  procedure  or 
by  the  sound,  by  estimating  the  resistance  encountered  and  by  the 
permanence  of  the  reposition. 

Treatment. — Whether  the  complicating  metritis  should  first  be 
treated  or  the  disj3lacement  reduced  is  a  disputed  question.  I  think 
it  is  well  to  treat  the  inflammation  first,  and  for  this  purpose  to  employ 
the  curette  followed  by  injections,  and,  in  case  of  metritis  which  is 
chronic  and  painful  [with  cervical  laceration  and  hyperplasia],  to 
amputate  the  cervix  [or  perform  Emmet's  operation]  (p.  206  et  seq.). 
It  is  not  unusual  to  see  the  pains  of  retroflexion  cease  when  the  me- 
tritis has  been  cured,  and  also  a  certain  degree  of  reduction  may  re- 
sult from  the  subsequent  involution.  It  is  well  in  special  cases  to 
dilate  the  cervix,  before  curetting,  with  laminaria  tents,  which  effec- 
tually begin  the  work  of  straightening  the  canal. 

If  with  the  metritis  there  is  also  an  acute  perimetritis,  with  peri- 
salpingitis, this  should  be  treated  by  appropriate  means  (hot  injec- 
tions, baths,  application  of  iodine,  glycerin  tampons  to  the  cervix, 
etc.),  and  only  when  all  inflammatory  symptoms  have  ceased  should 


.440 


CLINICAL   AND    OPEEATIYE   GYNAECOLOGY. 


we  make  an  effort  to  reduce  the  uterus  and  maintain  it  in  place;  the 
contrary  practice  advised  by  Poullet 12  appears  to  me  unwise. 

Reduction  of  Retroflexion. — This  maybe  accomplished  in  many 
ways: 

1.  By  the  Genu-pectoral  Position.18 — When  the  woman  has  been 
put  in  the  genu-pectoral  position  with  the  legs  a  little  separated,  and 
the  fourchette  retracted  so  as  to  allow  the  entrance  of  air  into  the 
vagina,  the  viscera  fall  toward  the  concavity  of  the  diaphragm  (Fig. 
230)  and  the  retroverted  or  retroflexed  uterus,  if  freely  movable,  is 
restored  to  its  normal  position.  This  reduction  may  be  aided  by 
keeping  the  vaginal  walls  separated  and  applying  traction  to  the 
posterior  cul-de-sac  with  a  speculum  blade  which  depresses  the  four- 


Fig.  230. — Reduction  of  Retroflexion  in  the  Genu-pectoral  Position. 

chette.  This  "  spontaneous  reposition  by  air,"  as  Courty  terms  it,  is  a 
valuable  exercise  which  the  patient  may  every  day  repeat,  morning 
and  evening,  for  a  few  moments,  placing  herself  in  the  attitude  of  a 
praying  Mahometan."  Tarnier 14  advises  the  patient,  when  she  takes 
this  position,  to  introduce  a  small  speculum  of  wire  or  simply  an  in- 
jection nozzle  into  the  vagina  to  facilitate  th  entrance  of  air  and  the 
upward  movement  of  the  uterus.  E.  Mosher15  recommends  his  pa- 
tients to  pass  the  finger  into  the  vagina  and  press  upon  the  anterior 
face  of  the  cervix,  which  has  the  effect  of  making  the  uterus  revolve 
forward.  If  this  procedure  is  not  sufficient  for  many  cases,  it  is  still 
a  valuable  auxiliary  where  the  trouble  is  not  inveterate.  Patients 
should  also  be  advised  to  sleep  on  the  face  or  side. 

[In  using  the  genu-pectoral  position  it  is  necessary  to  see  that  there 
are  no  constricting  bands  or  corsets  about  the  waist  to  interfere  with 


DISPLACEMENTS    OF   THE   UTERUS. 


441 


the  free  forward  and  upward  falling  of  the  abdominal  viscera.  If  after 
the  perineum  is  retracted  and  the  vagina  allowed  to  "  balloon "  (an 
effect  caused  by  the  traction  of  the  inverted  abdominal  contents)  the 
fundus  remains  fixed  behind  the  sacral  promontory,  it  may  often  be 
dislodged  by  drawing  the  cervix  down  toward  the  vulvar  opening  and 
backward  by  a  tenaculum  forceps,  and,  if  this  is  not  sufficient,  by  pres- 
sure at  the  same  time  against  the  fundus  by  the  fingers,  or  a  wad  of 
gauze  held  in  a  dressing  forceps.     Occasionally,  especially  where  we 


Fig.  231.— Bimanual  Reduction  of  a  Retroversion  or  Flexion.    First  step.    Elevation  of  the  uterus. 


have  to  do  with  an  incarcerated  retroflexed  gravid  uterus,  it  may  be 
necessary  to  employ  manual  pressure,  or  a  colpeurynter,  through  the 
rectum.] 

2.  Bimanual  Reduction. — The  patient  may  be  put  in  Sims'  posi- 
tion, or  even  in  the  genu-pectoral  if  necessary;  two  or  three  fingers  of 
the  left  hand  are  then  placed  in  the  rectum  or  the  vagina,  and  the 
cervix  is  pressed  backward,  while  the  right  hand  on  the  abdominal 
surface  endeavors  to  seize  the  fundus  and  bring  it  into  the  position 
of  anteversion ;  the  new  position  of  the  organ  must  be  exaggerated 
to  successfully  combat  the  tendency  to  return  to  the  displacement. 


442 


CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 


This  manoeuvre  may  be  much  simplified  by  seizing  the  cervix  with 
tenaculum  forceps  and  drawing  it  gently  downward.16 

Schultze 1?  has  advised  in  difficult  cases  to  introduce  the  finger  into 
the  previously  dilated  cavity  of  the  uterus ;  and  by  energetic  traction 
thus  exerted  directly  upon  the  uterine  tissues,  break  up  any  adhesions 
which  have  formed  between  the  organ  and  other  structures  which  op- 


Fig.  232.— Bimanual  Reduction  of  a  Retroversion  or  Flexion.    Second  Step.    Placing  the  reduced 
uterus  in  a  position  of  anteversion. 


pose  the  reduction.  He  describes  minutely  the  method  of  freeing 
the  uterus  from  pseudo-ligaments  and  adhesions  which  fix  it  behind 
or  laterally  or  on  its  surface  to  the  rectum.  Under  anaesthesia  he 
claims  that  he  can  feel  the  ovaries  and  destroy  their  adhesions. 
This  bold  practice  has  found  imitators,  but  it  has  also  been  condemned 
Schroder).  It  is  true  that  Schultze  has  obtained  very  remarkable 
success  in  this  way,  but  if  the  tubes  should  be  inflamed,  the  method, 
it  seems  to  me,  would  be  very  dangerous. 


DISPLACEMENTS   OF   THE   UTERUS. 


443 


3.  Redaction  by  tlie  Sound. — This  is  the  method  which  is  generally 
employed,  and  which  even  Schultze  advises  whenever  it  is  neces- 
sary to  overcome  resistance  of  unusual  degree.  Either  the  genu-pec- 
toral  or  Sims'  position  may  be  adopted.  A  large  smooth  metallic 
sound  is  selected  and  introduced  many  times  consecutively  to  reduce 
the  deformity  to  a  retroversion ;  then  the  sound  is  made  to  describe 
an  arc  of  a  circle,  and  the  beak  of  the  instrument  within  the  uterine 


Fig.  233. — Replacement  of  a  Retroflexed  Uterus  by  the  Sound. 


cavity  performs  a  rotation  which  carries  its  concavity  forward.  The 
uterus  is  thus  straightened  but  is  still  in  the  retro-position ;  to  bring 
it  forward,  the  handle  of  the  sound  is  depressed  toward  the  f ourchette 
(Fig.  233). 

In  all  these  manoeuvres  no  sadden  rough  movements  should  be 
performed,  but  the  pressure  should  be  gentle  and  continuous.  It  is 
well  to  precede  the  reposition  of  the  organ  by  dilatation  with  lami- 
naria  tents,  which  gives  suppleness  to  the  tissues,  and  the  mucous 


444 


CLINICAL'  AND   OPERATIVE   GYNECOLOGY. 


membrane  which  is  so  often  diseased  at  the  isthmns  shonld  be  cu- 
retted; the  reduction  may  then  be  completed  in  one  session.  At  other 
times  it  is  of  advantage  to  divide  the  treatment  over  several  sittings, 
repeating  them  every  two  or  three  days :  after  each  one  the  amount 


Fig.  234.— Annular  Pessary  op  Dumontpallier  in  Place,  in  a  Case  of  Retroflexion  Which  it  is 
Changing  to  Retroversion;  Reduction  may  Follow  Spontaneously. 

of  improvement  obtained  may  be  preserved  by  carefully  filling  the 
posterior  vaginal  pouch  with  iodoform  gauze;  finally  the  pessary  may 
be  introduced.  The  most  simple  instrument  for  reducing  the  uterus 
is  the  sound ;  I  prefer  it  to  all  the  various  repositors  which  have  been 
invented.18 


Fig.  235.  —Hodge  Pessary  with  Anterior  Depression  to  Avoid  Compressing  the  Urethra. 

[It  is  to  be  remembered  that  this  method  of  instrumental  reposition 
is  only  to  be  employed  after  a  most  careful  examination  has  shown  the 
probable  absence  of  any  recent  parametritic  trouble  or  of  marked  dis- 
ease of  the  uterine  appendages,  and  that  in  its  employment  the  most 
scrupulous  asepsis  is  to  be  maintained.  With  these  precautions,  and 
remembering  that  to  avoid  mechanical  injury  to  the  uterine  tissue  the 


DISPLACEMENTS    OF   THE    UTERUS. 


445 


sound  should  be  inserted  only  to  within  a  quarter  of  an  inch  of  the 
fundus  and  the  finger  tip  in  the  vagina  and  not  the  cervix  used  as 
a  fulcrum,  the  method  is  comparatively  safe.] 

Fixation  of  tlie  Reduced  Uterus. — For  this  purpose  we  may  em- 
ploy either  prothetic  measures  (pessaries)  or  various  operations. 

Pessaries. — A  simple  tampon  of  cotton  in  the  posterior  pouch  is 
a  means  of  maintaining  the  uterus  and  is  easily  renewed,  but  it  is  bet- 


Fig.  236. — Introduction  of  a  Hodge  Pessary  in  a  Case  of  Retroflexion   (Which  Should  First  be 

Reduced). 

ter  to  employ  an  indifferent  joessary,  like  D  union  trjallier's  ring,  which 
has  at  times  caused  the  reposition  of  the  organ  without  the  surgeon's 
efforts  by  the  steady  pressure  which  it  exerts  (Fig.  234).  [Ring  pes- 
saries of  either  hard  or  soft  rubber,  while  often  effective,  are  objec- 
tionable because  of  the  stretching  of  the  vagina  which  they  cause.] 
A  better  instrument  is  the  Hodge  pessary  with  a  double  curve  (Figs. 
235,  236,  and  237). 

The  pessary  should  be  chosen  to  fit  each  case.     If  too  small  it  is  of  no 
value,  if  too  large  it  becomes  intolerable.     If  the  perineum  is  resistant, 


446 


CLINICAL   AND   OPERATIVE   GYNECOLOGY. 


the  pessary  may  be  a  little  narrowed  below  (Albert  Smith's) ;  this  would 
be  an  inconvenience  in  the  contrary  condition.  It  is  well  to  have  a 
small  depression  in  the  anterior  portion  to  avoid  injury  to  the  ure- 
thra (Fig.  235).  The  most  convenient  kind  of  pessary  is  that  formed 
of  one  thickness  of  strong  copper  wire  and  covered  with  rubber;  they 
may  be  instantaneously  modified,  and  yet  they  are  resistant  enough. 
As  a  matter  of  fact,  the  surgeon  should  know  how  to  adapt  his  in- 
strument to  each  case  by  giving  more  or  less  sweep  to  its  curves. 
Hard-rubber  pessaries  are  also  very  good,  unalterable,  and.  can  be 
softened  in  hot  water  so  that  their  form  can  be  changed.  In  difficult 
cases  I  model  a  pessary  of  flexible  tin,  and  when  I  am  certain  that  it  is 


Fie.  237.— Hodge  or  Smith  Pessary  in  Place  after  Reduction  of  Retrodeviation. 

of  the  shape  exactly  adapted  to  the  case  I  copy  it  in  aluminum,  which 
is  both-light  and  resistant,  though  the  vaginal  secretions  alter  it  and 
it  has  to  be  frequently  renewed.  The  lower  extremity  of  a  pessary 
should  always  rest  a  little  above  the  meatus. 

Gaillard  Thomas  has  devised  a  pessary  which  resembles  the  Smith, 
except  that  it  has  its  posterior  bar  thickened  [and  Munde  has 
still  further  modified  this  by  making  it  shorter  and  broader  (Fig. 
239)]. 

The  Hodge  or  Smith  pessary  should  be  introduced  with  the  patient 
lying  on  the  side;  it  is  covered  with  vaselin  and  presented  at  the  vulva 
in  such  a  manner  that  it  shall  glide  flatwise  along  one  of  the  lateral  va- 
ginal walls.  While  the  labia  are  separated,  the  perineum  is  strongly 
depressed  (Fig.  236) ;  then  when  the  pessary  has  passed  the  introitus, 


DISPLACEMENTS   OF  THE   UTERI'S.  447 

it  is  easily  turned  about  in  the  larger  superior  portion  of  the  canal.  It 
then  glides  upward  and  backward,  describing  a  spiral  along  the  pos- 
terior wall.  A  slight  pressure  on  its  posterior  bar  carries  it  beyond  the 
cervix  into  the  jposterior  vaginal  pouch  and  it  thus  occupies  an  oblique 
position  from  above  downward  and  from  behind  forward.  The  abdomi- 
nal pressure  acting  upon  the  pelvic  floor,  constantly  but  with  increased 
force  in  all  efforts,  tends  to  make  the  pessary  take  a  horizontal  posi- 
tion, and  it  thus  oscillates  about  an  imaginary  axis  which  passes 
through  the  middle  of  its  transverse  diameter,  so  that  while  the  in- 
ferior arc  is  depressed  the  superior  is  lifted,  owing  to  the  obliquity  of 
the  wall.  The  jposterior  cul-de-sac  is  therefore  stretched,  the  cervix 
drawn  backward  according  to  the  degree  of  the  abdominal  pressure, 
and  the  uterus  as  a  whole  carried  forward  if  the  retroflexion  has  been 
reduced  previously.  It  is  not  unimportant  to,  remark  that,  even  when 
this  reduction  has  been  incomplete,  some  benefit  may  often  be  obtained 


Fig.  238.— Albert  Smith  Pessary  for  Retroversion.     Fig.  239.— Munde  Pessary  with  Thickened  Pos- 
terior Bar  for  Use  in  Retroflexion. 

by  either  the  ring  or  the  Hodge  pessary;  the  instrument  then  acting 
simply  by  diminishing  the  mobility  of  the  uterus. 

The  cradle  pessary  with  a  simple  curve,  much  recommended  by 
Olshausen  and  Schroder,19  has  the  advantage  of  not  descending  so  far 
as  the  Hodge  and  also  of  sustaining  the  anterior  vaginal  wall,  but  it 
is  not  so  powerful  as  the  doubly  curved  lever  form  (Figs.  238  and  240) ; 
it  is  specially  adapted  to  cases  where  there  is  some  relaxation  of  the 
anterior  wall. 

If  the  patient  takes  a  douche  twice  a  day,  the  pessary  may  be  left 
in  place  for  two  or  three  months ;  at  the  end  of  this  time  it  should  be 
withdrawn  and  careful  account  taken  of  the  position  of  the  uterus;  if 
it  remains  in  the  position  of  anteversion,  the  pessary  is  given  up, 
otherwise  its  use  must  be  continued.  The  accidents  which  have 
been  described  as  the  effect  of  forgotten  pessaries  are  due  to  their  com- 
plete neglect  for  years,  with  no  attempt  toward  cleanliness. 

[The  Albert  Smith  type  of  pessary,  both  with  and  without  the 


448 


CLINICAL   AJSTD   OPERATIVE   GYNAECOLOGY. 


thickened  posterior  bar,  is  the  most  generally  useful,  and  it  is  seldom 
that  any  other  form  will  be  required  in  the  treatment  of  retro-displace- 
ments. This  is  employed  with  a  posterior  bar  having  a  gentle  sweep 
in  simple  retroversion,  and'  with  a  more  pronounced  curve,  up  to  90°, 
when  a  flexion  is  to  be  overcome. 

It  is  to  be  remembered  that  this  pessary  does  not  act  by  a  general 
over-distention  of  the  vagina,  but  by  pushing  up  the  posterior  cul-de- 
sac  and  thus  drawing  the  cervix  backward  and  upward.  When  prop- 
erly fitted,  it  should  cause  no  pain,  should  not  project  from  the  vagina 
or  be  felt  by  the  patient,  should  be  movable  and  small  enough  so  that 
the  finger  can  be  swept  between  it  and  the  vagina  at  every  accessible 

L 


Fig.  240. — Munde-Thomas'  Pessary  in  Place  after  Reduction  op  a  Retrodeviation. 

point  without  tension.  It  should  never  be  introduced  until  the  uterus 
has  been  replaced,  never  when  there  is  any  marked  tenderness  or  in- 
flammation present  in  any  part  of  the  pelvis.  The  patient  must  always 
be  told  that  she  is  wearing  a  pessary,  and  that  she  must  remove  it  by 
hooking  her  finger  over  the  anterior  bar  and  pulling  downward  if  it 
causes  pain  at  any  time.  She  must  keep  the  parts  clean  by  a  daily 
cleansing  warm  injection,  with  a  little  soda  bicarbonate  added.  In- 
jections of  alum  or  any  sulphate  are  to  be  avoided,  as  they  soon  cause 
the  pessary  to  become  roughened  by  incrustations.  The  pessary 
should  be  removed  at  least  once  in  three  months,  to  be  cleaned  and 
polished.  So  far,  no  better  material  has  been  found  than  polished  hard- 
rubber  of  good  quality.  While  it  is  truly  said  that  very  few  perma- 
nent cures  result  from  the  use  of  these  instruments,  they  are  most 


DISPLACEMENTS    OF   THE    UTERUS. 


449 


valuable  as  a  palliative  and  adjunct  to  other  treatment,  and  when  prop- 
erly and  intelligently  used  do  not  cause  harm. 

A  rjroperly  fitting  bar  pessary  does  not  interfere  with  coitus  or 
impregnation ;  and  should  the  latter  occur  the  pessary  should  be  worn 


Fig.  241. — Cradle  Pessary  in  Place  after  Reduction  of  a  Retrodeviation. 

until  the  uterus  has  become  so  large  that  there  is  no  longer  danger 
of  its  possible  retroversion  and  incarceration.] 

The  preceding  pessaries  act  indirectly  upon  the  cervix  by  the  ten- 
sion of  adjacent  parts ;  other  forms  of  the  instrument  have  a  direct 
action  upon  the  organ.     Schultze  uses  pessaries  of  the  form  of  the 


Fig.  242. — Landowski's  Pessaries. 


Fig.  243.— Schcltze's  Figure-of-Eight  Pessary. 


numeral  8,  which  encircle  the  cervix  and  lift  it  backward;  they 
are  made  of  copper  covered  with  rubber.  An  instrument  is  chosen 
whose  upper  curves  embrace  the  cervix  without  strangling  it,  and  the 
lower  ring  is  adapted  to  the  size  of  the  vagina  and  the  angle  of  the 
pubic  arch.    These  pessaries  are  best  for  nulliparae,  in  whom  the  vagina 

29 


450 


CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 


is  resistant  and  there  is  no  need  of  seeking  a  point  of  support  from 
the  pubis ;  in  the  latter  case  they  are  intolerable  (Figs.  243,  244). 

Landowski's  ingenious  pessaries  resemble  those  of  Schultze;  they 
are  made  of  flexible  tin,  and  the  T-shaped  stem  may  be  put  in  one 
direction  or  the  other  according  as  we  wish  to  employ  it  for  antever- 
sion  or  retroversion  (Fig.  242).  In  the  latter  case  the  stem  is  bent 
from  behind  forward  and  the  anterior  vaginal  wall  is  in  relation  with 
its  concavity ;  this  stem  abuts  against  the  pubes,  embracing  with  its 
recurved  extremity  the  fleshy  band  which  always  exists  behind  the 
symphysis,  but  whose  thickness  differs  in  different  subjects;  the  ring 
surrounds  ihe  cervix.     Before  it  is  applied  we  should  assure  ourselves 


Fig.  244.—  Schultze's  Figure-of-Eight  Pessary  in  Place  after  the  Reduction  of  a  Retrodeviation. 

by  palpation  through  the  rectum  that  the  fundus  is  reduced ;  then, 
with  the  pessary  in  place,  the  patient  must  be  made  to  walk,  sit,  lie 
down,  etc.,  to  determine  whether  she  is  incommoded  by  it ;  if  she  is, 
we  employ  a  smaller  size.  When  the  flexible  pessary  is  well  sup- 
ported, we  may  substitute  for  it  a  rigid  one  in  aluminum.  When 
the  perineum  is  very  flaccid  and  the  vagina  large  and  relaxed,  Schultze 
employs  a  pessary  with  a  cervical  rest  (Fig.  245),  which  resembles  the 
instrument  proposed  lately  by  Vulliet.  Fritsch 20  combines  Schultze's 
pessary  with  the  Hodge  made  of  hard-rubber,  especially  in  the  first 
days  after  reduction,  following  it  with  a  Hodge  pessary  strongly  curved 
(Fig.  246).  All  these  pessaries  are  best  inserted  in  Sims'  position  (lat- 
eral semiprone). 


DISPLACEMENTS   OF  THE   UTERUS. 


451 


Pessaries  have  been  devised  which  have  their  point  of  support  ex- 
ternally, like  the  liysterophores  used  in  prolapse;  they  are  all  incon- 
venient and  untrustworthy.  [The  Thomas-Cutter 21  is  sometimes  tem- 
porarily useful  where  the  posterior  vaginal  cul-de-sac  is  too  shallow 
to  permit  the  use  of  an  intra-vaginal  pessary,  its  action  tending  to 
stretch  and  deepen  this  pouch.] 

Pessaries  with  an  intra-uterine  stem  may  be  of  service  in  maintain- 
ing a  reduction  for  a  few  days,  especially  as  an  auxiliary  to  other 
methods.  Courty 22  replaces  the  uterus  with  the  sound  once  or  twice 
a  week,  introducing  a  galvanic  uterine  stem  for  a  few  hours  after 
each  session.  Alexander  also  maintains  the  organ  in  ante  version  with 
a  stem  pessary  after  shortening  the  round  ligaments.  These  are  the 
only  advisable  applications  of  these  instruments  in  retroflexion. 


Fig.  245.— Schultze's  Pessary  with  Cervical 
Rest,  ok  Sleigh  Pessary. 


Fig.  34(5.— Fritsch's  Pessary. 


Whatever  the  form  adopted,  there  are  many  cases  where  it  is  abso- 
lutely impossible  to  maintain  the  reduction.  Sanger,23  from  careful 
statistics  of  57  cases  treated  by  pessaries  in  his  practice,  obtained  but 
7  cures,  or  10.6$;  27  were  improved,  or  40.9$;  in  15  cases  there  was 
no  result  (24.7$)  beyond  moderation  of  the  subjective  symptoms. 

The  causes  of  failure  with  pessaries  may  be  either  extreme  mobil- 
ity of  the  uterus  or  relaxation  of  the  vagina  and  perineum;  in  the 
latter  condition  they  may  be  combined  with  the  use  of  a  perineal 
cushion,  which  often  affords  much  relief.  If  there  is  at  the  same 
time  procidentia  uteri  or  vagin?e,  plastic  operations  are  of  great 
service  in  providing  a  point  of  support  for  the  pessary. 

Patients  are  always  relieved,  especially  when  the  abdomen  is  very 
large,  by  an  abdominal  supporter  which  takes  off  the  weight  of  the 
viscera. 

Whatever  the  prothetic  measures  adopted,  there  are  many  patients 
who  cannot  be  cured  by  them ;  in  such  cases  we  must  have  recourse 


452  CLINICAL   AND   OPERATIVE   GYJSTiECOLOG-Y. 

to  operation.     There  are  two  of  these  which  merit  special  mention, 
viz.,  shortening  the  round  ligaments  and  abdominal  hysteropexy. 

The  Operation  of  Alquie- Alexander- Adams. — The  idea  of  re- 
storing or  elevating  the  uterus  by  shortening  the  round  ligaments, 
which  are  easily  accessible  to  the  surgeon  at  their  termination,  be- 
longs to  Alquie,24  of  Montpellier.  Two  English  surgeons  reinvented 
the  operation  and  performed  it  at  about  the  same  time,  and  it  is  only 
just  to  connect  their  names  with  that  of  our  compatriot. 

The  operation  is  performed  to  maintain  the  reduction  in  retroflexion 
and  for  prolapse;  I  will  return  to  it  in  considering  the  lat'ter  subject. 
.It  was  very  coldly  received  in  England,25  Germany,26  and  France.27 
It  was  asserted,  after  insufficient  and  unfortunate  investigation,  that 
the  round  ligaments  were  not  to  be  found  outside  the  inguinal  ring. 
A  reaction  then  followed  and  the  operation  to-day  has  many  partisans, 
although  its  precise  indications  and  its  advantages  are  far  from  being 
correctly  appreciated. 

In  my  description  of  the  technique  I  base  my  remarks  on  Alex- 
ander's paper  and  on  my  own  experience.28  The  operation  should 
always  be  preceded  by.  curettage  as  a  preliminary  step. 

First  and  Second  Steps — Discovery  of  the  Ligaments. — Having 
found  the  pubic  spine,  an  inch-and-a-half  incision  is  made  over  it  in 
the  line  of  the  inguinal  canal  down  to  the  muscles.  With  the  finger 
the  non-resistant  point  of  the  external  inguinal  ring  is  found  and 
laid  bare,  avoiding  the  intercolumnar  fibres  which  limit  the  ring 
above  and  externally.  The  cellular  layer  which  stretches  between 
the  pillars  of  the  ring  is  then  cut  and  a  cushion  of  fine  yellow  fat, 
upon  which  Imlach 29  insists,  pouts  out  of  the  wound.  The  genital 
branch  of  the  genito-crural  nerve  is  then  drawn  aside,  and  with  a 
grooved  director  the  round  ligament  is  sought.  It  may  be  recognized 
by  its  reddish  cord-like  aspect,  a  little  striped  at  its  lower  extremity 
(Fig.  247) ;  it  is  then  seized  with  forceps  and  isolated  with  a  blunt  in- 
strument. The  wound  is  then  covered  with  an  antiseptic  pad  and  the 
same  manoeuvre  repeated  on  the  other  side. 

[The  ligament  is  more  easily  found  toward  the  upper  limit  of  the 
external  ring.  If  a  nick  is  made  in  the  intercolumnar  fascia  and  the 
opening  made  to  gape  by  drawing  it  back  with  a  strabismus  hook, 
while  another  is  passed  down  on  the  outside  of  the  grayish  mass  seen 
through  the  opening  and  its  point  turned  inward,  a  mass  of  tissue 
is  easily  secured  which  when  freed  from  the  accompanying  nerve  is 
easily  recognized  as  the  round  ligament.     Fibres  are  found  which  do 


DISPLACEMENTS    OF   THE   UTERUS. 


453 


not  draw  on  the  borders  of  the  ring,  and  by  steady  traction  on  these 
the  glistening,  smooth  cord  of  the  ligament  emerges.] 

Third  Step — Reposition  of  the  Uterus. — Alexander  prefers  to  re- 
place the  uterus  with  a  sound  which  an  assistant  passes  into  the  organ, 
aiding  the  reduction  by  means  of  bimanual  palpation,  while  the  sur- 
geon uncovers  the  wounds,  seizes  the  ligaments,  and  isolates  them  with 
the  spatula  or  by  cutting  the  fibrous  bands  which  hold  them  with  the 
scissors.  They  are  drawn  out  a  distance  of  about  ten  centimetres. 
Four  or  five  centimetres,  which  some  operators30  have  considered 
enough,  does  not  accomplish  a  satisfactory  reduction.  To  avoid  wound- 
ing the  serous  membrane,  Duplay 31  has  proposed  to  put  a  ligature 


MwlOTiiiT 


ESS" 


Fig.  247. — The  Round  Ligament  at  the  External  Abdominal  Ring. 

round  that  portion  of  the  ligament  which  is  farthest  up  the  canal; 
thus  if  the  inf  undibulif  orm  process  of  the  peritoneum  has  been  drawn 
down,  it  is  tied  off  by  the  ligature.     I  do  not  practise  this  manoeuvre. 

The  two  ligaments  must  be  treated  with  the  same  traction  and 
they  should  come  with  but  little  force,  especially  when  the  assistant 
aids  the  reduction  by  the  sound ;  this  easy  extraction  need  not  cause 
any  fear  that  they  have  been  torn  within  the  abdomen.  Resistance  is 
felt  when  the  uterus  is  replaced,  and  movements  of  the  sound  in  the 
organ  will  be  transmitted  to  the  ligaments. 

Fourth  Step— Suture  of  the  Shortened  Ligaments;  Closure  of 
the  Wound.— The  surgeon  confides  to  an  assistant  the  charge  of  keep- 
ing the  ligaments  moderately  tense  while  he  prepares  to  suture  them. 
A  curved  needle  with  silk  is  passed  through  the  external  pillar  and 
the  ligament  toward  its  upper  border  and  lastly  through  the  internal 


454  CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 

pillar,  so  that  the  stump  of  the  ligament  is  firmly  united  to  the  mar- 
gin of  the  external  orifice  of  the  inguinal  canal.  A  second  suture  is 
passed  through  the  lower  portion  of  the  ligament;  then  all  that  part 
of  the  fibrous  cord  which  is  beyond  these  sutures  is  cut  off.  If  it 
has  been  necessary  to  open  the  canal  and  divide  the  intercolumnar 
fascia,  the  incision  should  be  closed  with  catgut;  even  when  these 
parts  have  not  been  cut,  I  am  accustomed  to  close  the  ring  by  a  deep 
catgut  suture,  which  thus  forms  the  lowest  of  the  different  planes  of 
superimposed  sutures  which  I  employ  for  the  closure  of  the  wound. 
It  is  useless  to  drain  if  the  wound  is  clean  and  the  search  for  the 
ligament  has  not  been  difficult.  Antiseptic  dressing,  with  slight 
compression. 

Casati,32  of  Rome,  has  proposed  a  modification  of  the  technique, 
making  a  curved  incision  from  one  ring  to  the  other,  crossing  the  ex- 
tremities of  the  excised  ligaments,  and  fixing  them  with  a  deep,  con- 
tinuous catgut  suture.  Doleris,33  in  cases  where  the  ligaments  are 
thin,  adopts  a  procedure  similar  to  the  above,  with  the  difference 
that  the  crossing  and  suturing  of  the  ligaments  is  made  under  the 
skin  and  not  exposed.  The  free  end  of  the  right  ligament  cut  at  its 
pubic  insertion  is  seized  by  forceps  introduced  from  the  opposite 
side,  and  carried  under  the  skin  above  the  pubes  to  meet  the  end  of 
the  other.  The  left  ligament  is  sutured  to  its  pillars,  the  free  portion 
is  resected,  and  its  free  extremity  placed  in  contact  with  that  of  the 
opposite  ligament,  the  two  trunks  are  freshened  and  sutured  with 
catgut ;  drainage.  Segond 34  fastens  the  round  ligament  in  the  supe- 
rior angle  of  the  ring  by  a  suture  of  silk;  then,  in  the  middle  of  the 
two  pillars  on  their  free  borders  and  parallel  to  them,  he  makes  a 
short  incision  like  that  which  Reverdin  has  advised  in  the  radical 
operation  for  hernia ;  he  thus  obtains  two  small  button-holes  which 
he  uses  in  tying  the  ligament  round  the  pillars.  Seizing  the  end  of 
the  ligament,  it  is  passed  from  behind  forward  through  one  of  the 
openings,  then  through  the  other  from  before  backward,  and  finally 
made  to  emerge  in  the  superior  angle  of  the  ring,  which  thus  forms 
an  actual  knot  and  is  then  fastened  with  one  or  two  sutures  which 
diminish  the  ring  and  give  more  solidity  to  the  fixation  of  the  liga- 
ment. I  consider  the  procedure  which  I  have  given  more  simple  and 
equally  effectual. 

Fifth  Step. — Alexander  considers  it  of  great  importance  to  main- 
tain the  uterus  in  a  good  position  during  convalescence,  with  a  stem 
pessary  to  keep  it  straight  and  a  Hodge  to  insure  anteversion.     Th<^ 


DISPLACEMENTS    OE   THE    UTERUS.  45'5 

ligaments  are  thus  relieved  from  the  traction  which  the  uterus  does 
not  fail  to  exert  upon  them  by  its  tendency  to  reproduce  the  displace- 
ment. The  pessary  should  be  retained  during  the  first  month,  which 
the  patient  spends  in  bed  [and  for  several  months  after].  I  have  aban- 
doned the  stem,  but  it  is  well,  I  think,  to  maintain  the  uterus  and 
thus  relieve  the  ligaments  either  with  the  Hodge  or  by  means  of  an- 
tiseptic tampons  frequently  renewed. 

Gravity  of  the  Operation  ;  Results  ;  Indications. — At  the  end  of 
the  work  which  I  have  cited,  Alexander  mentions  twenty-six  cases  of 
retroversion  and  retroflexion  upon  which  he  had  operated  up  to  June, 
1885,  with  permanent  success.  It  is  evidently,  then,  a  benign  opera- 
tion. But  Alexander  states  that  death  may  occur  in  exceptional  cir- 
cumstances, as  after  every  surgical  procedure,  however  small,  having 
known  three  cases,  in  his  own  experience,  from  pysemia  due  to  con- 
tagion. Many  cases  have  been  recently  published  in  France  and  else- 
where by  Trelat,  Doleris,  Schwartz,  Terrillon,35  who  have  obtained 
great  advantages  from  the  operation  in  retroflexions  which  were  easily 
reduced,  with  no  accidents.  Fatal  cases  have  been  described  by  for- 
eign writers,  Harrington 36  having  collected  140  cases,  with  3  deaths, 
from  21  operators.  The  ojjeration  is  now  generalized  and  is  prac- 
tised everywhere,37  with  variable  success,  which  appears  to  depend 
upon  the  degree  of  clearness  with  which  the  indications  are  appreci- 
ated.    Besides  the  important  discussions  at  the  Paris  Surgical  Society, 


38 


I  would  mention  those  of  the  Congress  of  Gynaecology  at  Munich 
and  at  the  Congress  at  Halle.39 

It  seems,  then,  that  the  operation  of  Alquie- Alexander  is  suscep- 
tible of  giving  excellent  and  permanent  results  in  retroflexions  of  the 
uterus.  In  simple  cases  a  pessary  may  be  preferable ;  but  where  it  is 
difficult  to  apply,  and  is  not  well  borne,  shortening  of  the  round  liga- 
ments is  a  valuable  resource;  we  should  thus  be  able  to  cure  even  bed- 
ridden patients ;  but  it  is  well  to  know  that  cases  which  are  rebellious 
to  the  pessary  sometimes  bring  disappointment,  even  after  operation; 
Kiistner 40  and  Keith 41  have  published  instructive  cases  of  this  variety. 

Trelat 4a  has  performed  Alexander's  operation  forty  times,  of  which 
five  were  for  movable  or  adherent  retroversion,  which  were  previously 
reduced  in  repeated  sessions,  and  obtained  excellent  results.  He 
clearly  formulates  the  rule  that  shortening  of  the  round  ligaments 
seems  to  be  the  operation  directly  indicated  to  maintain  in  antever- 
sion  a  uterus  which  was  previously  fixed  by  adhesions  in  retro- 
flexions, mobilized  by  treatment,  but  unable  to  preserve  the  position 


456  CLINICAL   A1STD   OPERATIVE   GYNAECOLOGY. 

itself  or  by  pessary.  Moreover,  since  retrodeviations  seemed  to  him 
to  constitute  an  actual  menace  to  the  patient,  in  view  of  the  almost 
constant  complication  of  metritis  and  salpingitis  provoking  adhesions, 
he  considered  it  good  practice  to  intervene  in  retroversions  which 
were  absolutely  indolent,  and  thus  to  guard  against  possible  acci- 
dents. This  principle  seems  to  me  to  extend  the  field  of  operation 
far  too  widely.  I  am  inclined  rather  to  accept  Munde's 43  advice,  who, 
although  a  great  partisan  of  the  operation,  reserves  it  for  painful 
deviations  which  are  easily  reducible. 

[is  early  all 44  those  who  have  had  practical  experience  with  Alex- 
ander's operation  have  declared  in  its  favor,  and  it  will  undoubtedly 
continue  to  be  done  successfully  in  properly  selected  cases  and  with 
accessory  operations  for  lessening  the  weight  of  the  uterus,  narrowing 
the  vaginal  walls,  and  repairing  the  torn  perineum.45 

The  greatest  value  of  the  operation  is  in  old  cases  of  retroversion 
and  flexion,  especially  when  associated  with  descent  or  prolapse  and 
with  more  or  less  anterior  or  posterior  colpocele;  that  is,  when  the 
plevic  floor  is  injured  beyond  non-operative  restoration.  To  these  in- 
dications may  be  added  (Kellogg)  displacement  accompanied  by  pro- 
lapse of  the  ovaries,  so  that  the  wearing  of  a  pessary  is  not  practicable. 
The  presence  of  adhesions  is  an  absolute  contraindication,  except 
where  they  can  be  broken  by  gentle  manipulation.  When  Alexander's 
orjeration  is  contra-indicated  or  inefficient,  other  methods  are  to  be 
employed.  These  fall  into  two  distinct  categories,  one  utilizing  the 
natural  supports,  the  other  creating  new  supports  and  each  having 
its  own  sphere  of  usefulness.] 

Colpo-Tiysteropexy  and  Vaginal  Hysteropexy. — The  first  attempts 
to  fix  the  uterus  by  way  of  the  vagina,  after  it  had  been  reduced  to  a 
good  position,  date  from  the  time  of  Amussat,46  who,  in  case  of  ver- 
sion, either  forward  or  backward,  employed  the  hot  iron  and  cauterized 
the  side  opposite  to  the  displacement  to  produce  a  cicatricial  bridle 
which  would  restore  the  organ.  Courty 47  claimed  to  have  obtained 
very  good  results  from  this  singular  treatment  in  cases  of  anteversion, 
and,  although  he  did  not  reject  it  in  retroversion,  declared  that  there 
was  here  some  danger  to  the  adjacent  peritoneum. 

With  the  same  object  a  transverse  fold  of  the  vagina  has  been 
sutured  in  such  a  way  as  to  shorten  one  or  the  other  wall  of  the  canal ; 
Sims  performed  this  three  times  for  anteversion. 

Richelot,  Sr.,4s  has  proposed  to  consolidate  the  cervix  with  the 
posterior  wall  of  the  vagina,  and  Byford49has  performed  an  analo- 


DISPLACEMENTS   OF  THE   UTERUS. 


457 


gous  metro-elytrorrhaphy  in  patients  who  had  passed  the  menopau.se, 
uniting  the  anterior  vaginal  wall  on  the  anterior  surface  of  the  cervix 
with  the  posterior  wall  of  the  vagina.  Doleris 50  practised  pre-  or 
retro- cervical  colporrhaphy  in  similar  cases,  after  having  reduced  the 
displacement. 

When  the  anterior  vaginal  wall  appears  too  short,  Skutsch 51  pro- 
poses to  lengthen  it  by  a  transverse  incision,  which  is  then  sutured 
longitudinally. 

.  Schiicking 32  fixes  the  fundus  of  the  uterus  to  the  vesico-uterine 
cul-de-sac  by  means  of  a  double-threaded,  strongly-curved  needle 


Fig.  248.— Vaginal  Hysteropexy.    Schucking's  Operation. 

cachee,  introduced  into  the  replaced  and  dilated  uterus,  with  which  he 
pierces  the  vaginal  fundus  and  vaginal  pouch  below  the  bladder,  tying 
the  suture  so  as  to  have  the  uterus  in  an  exaggerated  position  of  an- 
teflexion. The  suture  is  removed  from  the  tenth  to  the  fourteenth  day, 
when  the  exaggerated  anteflexion  disappears.  In  spite  of  reported 
successes,  this  adventurous  procedure  does  not  seem  to  me  worthy  of 
recommendation. 

Yon  Eabenau 53  has  proposed  to  incise  the  cervix,  then  to  open  the 
anterior  vaginal  pouch  and  separate  the  bladder  from  the  uterus  by 
a  dull  instrument;  the  anterior  wall  of  the  uterus  is  then  excised 
for  a  distance  of  four  centimetres  and  the  wound  sutured.  This  opera- 
tion has  been  imitated  by  Schmidt,54  of  Cologne.  Fraenkel55  has 
justly  observed  that  the  cervix  is  so  strongly  drawn  forward  by  the 
cicatricial  process  that  the  body  of  the  uterus  tends  to  fall  backward. 


458  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

Sanger 56  has  theoretically  adopted  the  idea  of  Schiicking,  but  his 
operation  of  suturing  the  fundus  to  the  anterior  vaginal  cul-de-sac  is 
different.  After  transverse  section  of  the  anterior  cul-de-sac  of  the  va- 
gina and  of  the  peritoneum  behind  the  bladder,  he  sutures  the  uterine 
body  to  the  vagina  with  silver,  uniting  the  vaginal  wound  on  a  vertical 
line  to  elongate  the  anterior  wall  of  the  canal  and  permit  the  cervix  to 
retire  backward. 

It  is  probable  that  both  the  attempt  and  the  realization  of  this 
ingenious  hypothesis  is  still  far  distant. 

Bichelot 57  has  warmly  recommended  a  procedure  of  Nicoletis  for 
the  purpose  of  elevating  the  uterus,  which  takes  its  point  of  support 
upon  the  posterior  vaginal  wall  and  peritoneum.  The  intra- vaginal 
portion  of  the  cervix  is  first  amputated,  then  on  its  posterior  aspect 
three  catgut  ligatures  are  passed  through  the  uterine  stump  and 
vagina  in  such  a  way  that  they  reappear  at  the  internal  uterine  os. 
These  three  threads  are  median ;  to  the  right  and  left  two  others  are 
passed,  taking  in  the  posterior  wall  of  the  vagina  and  emerging  on 
the  anterior  border  of  the  stump  so  that  the  posterior  vaginal  wall  is 
thus  suspeuded  from  this  border  of  the  uterine  section ;  coaptation  is 
completed  by  superficial  sutures.  The  entire  vaginal  insertion  is  car- 
ried forward,  and  the  wall  drags  upon  the  fundus  of  the  uterus  and 
rotates  it  forward  even  at  the  moment  of  operation  (Fig.  248).  This, 
I  think,  is  to  expect  a  mechanical  effect  to  be  permanent,  which  is 
really  only  an  illusion,  for  the  constant  extensibility  of  the  vagina 
and  the  frequent  flaccidity  of  the  perineum  reduce  the  procedure  to 
an  ingenious  theoretic  conception.  The  good  results  obtained  have 
been  due  only  to  cervical  amputation  and  its  effect  upon  the  me- 
tritis.^60 

Pelvic  Colpo-Tiysteropexy. — This  is  the  name  which  might  be  given 
to  the  operation  of  Freund61  in  cases  of  prolapse  or  serious  retroflexion 
with  a  largely  developed  Douglas'  pouch.  He  thinks  that  both  of 
these  displacements  may  be  due  to  persistence  of  the  great  extent  of 
this  cul-de-sac  in  the  foetus,  for  up  to  the  seventh  month  of  intra- 
uterine life  the  peritoneum  descends  to  the  middle  of  the  vagina. 
Freund  made  a  large  opening  in  the  posterior  vaginal  pouch,  entered 
the  peritoneum,  and  sutured  the  posterior  surface  of  the  supra- vaginal 
portion  of  the  cervix  to  the  serous  membrane  above  the  promontory 
near  the  utero-sacral  ligaments,  taking  care  not  to  wound  the  rectum ; 
then  he  packed  the  cavity  with  iodoform  gauze  and  partly  closed  the 
vaginal  wound;  afterward  he  restored  the  perineum  if  it  was  neces- 


DISPLACEMENTS   OF   THE   UTERUS. 


459 


sary.    It  does  not  seem  that  this  operation  is  more  benign  or  more 
efficacious  than  abdominal  hysteropexy. 

The  germ  of  Freund's  conception  was  found  in  the  propositions 
of  Schultze  and  Sanger.  Schultze 62  proposed  a  transverse  section  of 
the  posterior  cul-de-sac  of  the  vagina,  freeing  uterus  and  adnexa,  re- 
position of  uterus,  and  obliteration  of  Douglas'  pouch  by  sutures  in 
such  a  way  that  the  cervix  would  be  drawn  backward.  Sanger 63  in- 
quired whether  curative  adhesions  could  be  produced  by  opening 
the  recto-uterine  pouch  and  tamponing  with  iodoform  gauze.    Freund 


Fig.  249.— Vaginal  Hysteropexy;  Nicoletis.  1.  Retroverted  uterus;  a,  b,  line  of  section;  c,  d,  vagi- 
nal walls.  2.  Uterus  replaced;  a,  insertion  of  the  two  vaginal  walls  upon  the  anterior  surface  of  the 
stump.  3.  Front  view  of  the  uterine  stump  after  supra-vaginal  amputation;  passage  of  the  three  median 
threads;  a,  vaginal  wall;  b,  anterior  edge  of  stump;  c,  uterine  orifice.  4.  Fixation  of  the  posterior  vaginal 
wall  to  the  uterine  orifice;  passage  of  the  two  lateral  threads.  5.  Fixation  of  the  posterior  vaginal  wall  to 
anterior  border  of  the  stump.    6.  Suture  complete. 

thought  of  alcohol  injections  in  the  neighborhood  of  the  utero-sacral 
ligaments  and  into  the  retro-cervical  cellular  tissue,  in  the  hope  of 
thus  producing  anteversion  by  the  contraction  of  these  ligaments. 
This  was  assuredly  a  great  risk,  exposing  the  parts  to  inflammation 
which  would  exceed  therapeutic  limits. 

Most  of  these  procedures  of  vaginal  hysteropexy  are  open  to  two 
objections — they  act  directly  upon  the  fundus,  and  fix  the  uterus  to 
tissues  which  are  movable  and  extensible,  which  is  not  the  case  in 
suture  of  the  uterus  to  the  abdominal  wall. 


460  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

Gastro-liysteropexy  or  Fixation  to  the  Abdominal  Wall  (ventro- 
fixation, gastro-hysterorrhaphy,  gastro-hysterosynaphy) : 

Historical  Review. — When  the  pedicle  of  an  ovarian  cyst  has  been 
fixed  in  the  abdominal  wound,  it  is  quite  common  to  find  that  a  pre- 
vious uterine  displacement  has  disappeared.  From  this  originated  the 
idea  of  purposely  fixing  the  uterus  to  the  abdominal  wall  by  means  of 
the  broad  ligaments,  with  or  without  removal  of  the  ovaries.  The  first 
operation  of  this  kind  was  performed  by  Kceberle.64  On  March  27th, 
1869,  in  a  difficult  case  of  retroflexion  which  had  caused  symptoms  of 
chronic  intestinal  obstruction,  he  incised  the  abdominal  walls,  brought 
the  uterus  forward,  removed  a  healthy  ovary,  and  sutured  the  pedicle 
to  the  lower  border  of  the  wound.  Sims 65  (February  22d,  1875)  per- 
formed laparatomy  on  a  woman  of  thirty-two  years  who  suffered  from 
an  extremely  painful  retroflexion,  removed  the  left  ovary,  which  was 
of  the  size  of  a  nut  and  in  cystic  degeneration,  and  sutured  the  pedi- 
cle in  the  lower  angle  of  the  wound  in  such  a  way  that  the  uterus 
was  held  in  its  normal  position;  the  patient  was  perfectly  cured. 
Schroder,68  a  little  later,  had  a  patient  who  suffered  from  retroflexion 
and  choreic  symptoms,  and  also  had  a  small  cyst  of  the  ovary,. upon 
whom  he  performed  laparatomy  and  fixed  the  pedicle  to  the  abdomen, 
curing  the  displacement  and  the  chorea.  Lawson  Tait,67  on  February 
20th,  1880,  practised  laparatomy  for  oophoritis  and  retroflexion  upon 
a  woman  whom  nothing  had  benefited.  He  found  the  ovaries  large 
and  soft  but  not  cystic,  and  removed  them ;  then  on  closing  the  ab- 
dominal wound  he  passed  a  suture  through  the  fundus  and  fastened 
the  uterus  to  the  wall.  A  second  operation  was  done  April  9th,  1880. 
Both  cases  remained  cured  in  1883.  Hennig68  in  1881,  in  a  case  of 
rebellious  retroflexion,  performed  castration  and  sutured  the  ovarian 
ligament  on  the  right  side  and  the  broad  ligament  on  the  left  into 
the  abdominal  wound. 

After  these  scattered  cases  without  definite  system,  Olshausen,69 
in  an  article  which  was  the  beginning  of  a  new  era,  published  an  im- 
proved method  including  three  remarkable  cases,  one  of  retroflexion 
and  two  of  xorolapse.  He  united  with  many  sutures  of  silkworm  gut 
that  portion  of  both  round  and  broad  ligaments  which  is  adjacent  to 
the  uterine  cornua  with  the  abdominal  wall,  taking  great  care  to  avoid 
the  epigastric  artery.  In  one  case  he  extirpated  the  ovaries  in  a 
patient  who  was  near  the  menopause,  but  remarks  that  this  contingent 
to  the  operation  was  purely  accidental. 

At  the  congress  where  Olshausen's  communication  was  made,  a 


DISPLACEMENTS   OF  THE   UTERUS.  461 

memoir  of  Fraenkel's  was  followed  by  a  discussion,70  and  a  number 
of  new  cases  were  cited  by  Bardenheuer  (reported  by  Frank)  and 
Czerny.  Soon  afterward  Kelly,71  in  Philadelphia,  published  an  in- 
teresting case  of  retroflexion  cured  by  ablation  of  one  ovary  and  fix- 
ation of  the  pedicle  to  the  abdomen,  together  with  a  partial  anal- 
ysis of  preceding  papers ;  the  other  ovary  had  been  extirpated  some 
time  before  by  the  vagina.  Kelly  published  at  the  same  time  two 
cases  of  castration  and  suture  of  the  broad  ligaments  to  the  abdomen 
by  Sanger.  Soon  after  the  latter  author  prepared  a  more  complete 
study  of  the  subject  with  7  personal  cases.72  Klotz,73  in  October,  1887, 
had  already  reported  to  the  Gynaecological  Society  of  Dresden  17 
cases  of  fixation  of  a  retroflexed  uterus  to  .  the  abdominal  wall  by 
means  of  a  pedicle  formed  of  the  tube.  Leopold,74  one  month  later, 
presented  3  successful  cases  after  fixation  of  the  fundus  in  the  abdom- 
inal wound.  In  1888  Kelly,75  in  America,  published  a  new  paper 
on  the  subject  with  several  new  cases;  4  of  P.  Zweifel's  for  retroflex- 
ion (hysterorrhaphy  without  castration)  and  1  of  Staude's  for  retro- 
flexion (hysterorrhaphy  with  ablation  of  one  ovary,  the  other  being 
so  adherent  that  it  could  not  be  extirpated).76  Phillips 77  published  1 
case  of  ventro-fixation  for  prolapse  in  England.  Schauta  has  reported 
4  cases  from  his  practice.78  Czerny79  has  given  4  cases  of  gastro- 
hysteropexy  and  described  his  method  in  an  important  memoir  which 
appeared  in  October,  1888.  In  France,  Terrier,  and  Picque  were  the 
first  to  perform  the  operation,  Terrier  in  August,  1888,  for  prolapse, 
and  Picque  in  September  for  retroflexion.80  Since  that  time  the  cases 
have  multiplied  in  France  and  elsewhere,  and  their  description  offers 
nothing  peculiar.81 

It  is  probable  that  many  gynaecologists  have  practised  occasional 
complementary  fixation  of  the  uterus  after  ablation  of  an  ovarian  cyst 
or  a  fibroma  or  to  remedy  a  retroflexion  or  a  prolapse,  without  pub- 
lishing: thus,  in  April,  1882, 1  fixed  the  pedicle  of  an  ovarian  cyst  and 
cured  a  prolapse.  The  case  was  mentioned  for  the  first  time  at  a  dis- 
cussion on  hysteropexy  and  rjublished  entire  by  Dumoret.S2  Czerny 83 
practised  an  analogous  suture  of  the  pedicle  of  the  ovary  for  retro- 
flexion June  15th,  1886,  but  did  not  publish  the  case  till  the  year 
1888.  At  that  time  he  had  done  the  complementary  operation  three 
or  four  times  in  forty- six  ovariotomies. 

With  these  complementary  hysteropexies  it  is  convenient  to  in- 
clude necessary  fixation  of  the  pedicle  after  supra-vaginal  amputa- 
tion 84  and  fixation  of  the  uterus  after  extirpation  of  a  subperitoneal 


462 


CLINICAL   AND   OPEKATIVE   GYNAECOLOGY. 


fibroma.S5  Brennecke,  of  Magdeburg,  has  sutured  the  uterine  cornu  of 
the  right  side  to  the  abdomen  in  the  course  of  an  ovariotomy  to  rem- 
edy a  prolapse;  success;  1883.     In  a  second  operation  of  ovariotomy 


VP-  — 


\o 


Fig.  250. — Gastro-hysteropexy  (OLSHAtrsEN  and  Saenger).    Profile  view  to  show  the  path  of  the  sutures. 
tr,  Tube;  Ir,  round  ligament;  lo,  ovarian  ligament. 

he  sutured  both  cornua  for  prolapse ;  failure ;  new  operation  on  the 
same  patient;  suture  of  ovarian  pedicle ;  1885.  With  the  exception, 
perhaps,  of  this  last  case,  these  operations  have  nothing  in  common 
with  hysteropexies  deliberately  proposed.    Werth,  of  Kiel,  performed 


Fig.  251. — Gastro-hysteropexy  (Olshausen  and  Saenger)  Front  view.  Two  of  the  sutures  for  clos- 
ing the  abdominal  wall  are  represented  as  cut  away  so  as  to  show  clearly  the  uterine  sutures  on  either  side 
which  have  already  been  tied. 

castration  for  hemorrhage  in  1887,  sutured  the  pedicle  to  the  wall, 
with  cure  at  the  same  time  of  extreme  retroflexion.  In  1884,  in  an- 
other operation  for  dermoid  cyst,  he  sutured  the  retroflexed  uterus  to 
the  vesical  peritoneum  with  silk;  this  is  not  ventro-,  but  vesico- 
hysteropexy,  or  cysto-hysteropexy.    A  case  of  Weist's,  cited  by  Kelly, 


DISPLACEMENTS   OF   THE   UTERUS.  463 

where  he  was  said  to  have  attached  the  ovarian  pedicle  to  the  abdo- 
men for  prolapse,  belongs  in  the  class  of  fortuitous  operations  and  is 
very  different  from  veritable  gastro-hysteropexy. 

Operative  Technique. — Three  chief  and  several  secondary  pro- 
cedures may  be  distinguished: 

1.  Indirect  Fixation  (Kceberle,  Klotz). — The  ovary  or  tube  being 
first  removed,  the  pedicle  is  fixed  in  the  abdominal  wound.  Klotz 
attaches  much  importance  to  the  use  of  a  glass  tube  behind  the  uterus 
in  Douglas'  pouch,  which  may  be  withdrawn  after  a  short  time,  and 
which  has  for  its  purpose  the  production  of  adhesions.  This  method 
has  the  defect  that  it  sacrifices  the  ovary,  twists  the  uterus,  and  pro- 
duces only  a  temporary  union;  it  has  often  failed.86 

2.  Direct  Lateral  Fixation  of  tlie  Fundus  (Olshausen,  Sanger). — 
Silkworm  gut  sutures  are  placed  on  each  side,  at  the  edges  of  the  fun- 
dus, as  shown  in  Figs.  250  and  251.  They  are  inserted  with  care  to 
include  only  the  anterior  serous  layer  and  not  to  ^fierce  the  tube  or  the 
epigastric  artery.  This  procedure  has  the  disadvantage  of  leaving 
a  cleft  or  button-hole  between  the  uterus  and  the  abdominal  wall 
which  may  cause  internal  strangulation.  Kelly's 87  method  resembles 
Olshausen's  and  does  not  need  special  description. 

3.  Direct  Median  Fixation  (Leopold,  Czerny,  etc.). — Leopold  also 
fixes  the  fundus  of  the  uterus  to  the  abdominal  wall.  The  abdomen 
is  opened,  the  uterus  replaced  after  rupture  of  adhesions,  and  then 
a  strong  needle,  armed  with  silk,  is  passed  from  before  backward,  a  lit- 
tle outside  of  the  border  of  the  wound,  through  the  whole  abdominal 
wall  at  the  level  of  the  fundus.  The  uterine  tissue  is  pierced  on  the 
elevated  surface  of  the  anterior  aspect  of  the  organ  in  a  line  with  the 
insertion  of  the  two  round  ligaments.  The  needle  is  passed  under  the 
serous  membrane  and  the  superficial  layer  of  the  muscle  for  a  distance 
of  one  centimetre,  and  then  through  the  other  lip  of  the  wound,  but 
this  time  from  behind  forward.  A  second  suture  is  then  inserted  above 
in  a  line  with  the  insertion  of  the  tubes  for  about  two  centimetres,  and 
a  third  a  little  above  this  one  in  the  same  manner  (Fig.  252). 

To  facilitate  the  adhesion,  Leopold  gently  scrapes  the  surface  of 
the  peritoneum  with  the  back  of  the  bistoury  over  that  portion  of 
the  uterus  which  is  circumscribed  by  the  sutures,  making  a  superficial 
freshening  which  does  not  bleed  and  simply  removes  the  epithelium. 
Then  he  unites  the  lips  of  the  abdominal  wound  at  that  level,  tying 
the  three  sutures  above  the  abdominal  wall  (Fig.  252)  so  that  the  an- 
terior surface  of  the  uterus  is  exactly  applied  to  the  parietal  perito- 


464 


CLINICAL   AND   OPERATIVE   GYNECOLOGY. 


neiim  at  this  point.  The  rest  of  the  wound  is  then  closed  below  and 
above.  The  uterine  sutures  are  removed  at  the  end  of  about  twelve 
days.  None  of  the  sutures  are  hidden.  Leopold 88  thinks  that  he  thus 
produces  lax  adhesions,  with  little  risk  to  the  bladder.  It  is  well  to 
insert  a  Hodge  or  Smith  pessary  for  the  first  month  to  prevent  strain 
on  the  sutures  and  maintain  the  good  position  gained. 

Czerny 89  pierces  the  abdominal  wall  near  the  fundus  with  a  very 
strong  needle  furnished  with  bichloride  catgut  (he  first  used  chromic 
catgut).  The  needle  passes  through  the  muscles  and  the  peritoneum 
and  then  the  opposite  side,  but  does  not  include  the  integument, 
which  is  a  capital  difference  between  this  and  Leopold's  method.    One 


Fig.  252.— Gastro-hysteropexy;  Leopold's  Method. 


or  two  threads  are  thus  placed  with  care  not  to  exert  traction  upon 
the  uterus,  a  point  being  selected  where  the  organ  may  be  easily  ap- 
plied to  the  abdominal  wall;  they  are  then  tied,  the  ends  cut  and  the 
wound  closed  (Fig.  253). 

Terrier's 90  procedure  is  a  variation  of  the  preceding.  He  begins 
by  placing  a  rjrovisional  suture  of  silk  in  the  fundus,  through  but 
little  of  the  tissue,  for  the  purpose  of  drawing  the  organ  upward. 
Large  catgut  is  used  for  the  three  permanent  sutures,  on  the  anterior 
surface  of  the  uterus.  The  first  is  passed  at  the  junction  of  cervix  and 
body,  the  next  at  the  middle  of  the  body,  and  the  last  near  the  fundus. 
The  threads  pass  through  the  superficial  layers  of  the  uterus,  and  the 
whole  thickness  of  the  abdominal  wall,  with  the  exception  of  the  cel- 
lular tissue  and  the  skin.  This  is  the  real  difference  between  Leo- 
pold's and  Terrier's  procedures;  the  latter  being  distinguished  from 
Czerny's  by  the  care  which  is  taken  to  pass  the  sutures  like  basting 


DISPLACEMENTS    OF   THE   UTERUS. 


465 


stitches  so  that  they  are  not  wholly  hidden  in  the  tissues  of  the  uterus 
but  a  portion  is  interposed  between  the  organ  and  the  abdominal  wall ; 
he  thinks  that  the  production  of  adhesions  is  thus  better  assured  (Fig. 


Fig.  253.— Gastro-hysteropexy;  Czerny's  Method. 


254).  The  threads  are  tied  and  form  a  "  suture  perdu,"  above  which 
the  integuments  are  brought  together,  superiorly  by  three  silver  su- 
tures through  the  peritoneum  and  below  by  three  strands  of  silkworm 
gut. 


Fig.  254. — Gastro-hysteropexy;  Terrier's  Method. 

My  own  preference  is  for  the  continuous  hem  suture  which  I  em- 
ploy, no  matter  how  great  the  extent  of  the  wound.  The  following  is 
the  simple  technique  of  the  operation: 

30 


466 


CLINICAL  AXD  OPERATIVE  GYNECOLOGY. 


First  Step. — Incision  of  the  abdominal  wall  in  the  median  line  for 
eight  centimetres,  beginning  a  finger's  breadth  above  the  pnbes. 

Second  Step. — Introduction  of  the  index  and  middle  fingers  of  the 
right  hand  iuto  the  wound,  liberation  of  the  uterus,  which  is  then 
drawn  forward,  during  which  time  an  assistant  raises  the  organ  by 
his  finger  in  the  vagina. 

Th  ird  Step. — Provisional  fixation  with  a  bullet  forceps  placed  su- 
perficially in  the  fundus  of  the  organ  where  the  punctures  do  not  cause 
hemorrhage,  intrusted  to  an  assistant  who  thus  raises  the  uterus.  The 
surgeon  theu  takes  a  Hagedorn  needle  furnished  with  fine  but  strong 


Fig.  255. — Gastro-Hysteropexy;  Pozzi's  Method.    Fixation  of  the  anterior  face  of  the  uterus  with  a  hem 

stitch  of  silk. 

silk,  and  passes  two  stitches  through  the  lower  part  of  the  wound 
including  the  whole  of  the  serous,  fibrous,  and  muscular  tissues  of  the 
abdominal  walls  in  such  a  way  as  to  establish  there  a  point  of  support. 
Starting  from  this  place  he  rapidly  makes  a  spiral  ascending  hem 
stitch  Avhich  includes  all  of  the  abdominal  tissues  except  the  skin  and 
subcutaneous  cellular  layer,  as  well  as  the  superficial  portion  of  the 
uterus  in  the  median  line  and  then  the  opposite  lip  of  the  incision ; 
three  or  four  of  these  stitches  are  enough.  As  soon  as  the  uterus  is 
fixed  to  the  abdominal  wall,  the  silk  suture  is  arrested  (Fig.  255). 

Fourth  Step. — The  remainder  of  the  wound  is  closed  by  a  hem  of 
catgut  on  two  planes  (Stage).  Two  sutures  of  silk  bring  together  the 
skin  and  cellular  tissue,  accurate  apposition  being  secured  by  a  super- 
ficial hem  of  catgut. 


DISPLACEMENTS    OF   THE    UTERUS.  467 

On  many  secondary  points  of  technique  surgeons  are  not  agreed. 
Should  the  suture  be  one  which  cannot  be  absorbed  (silk  or  silk- 
worm gut)  as  Leopold,  Olshausen,  Sanger,  and  Phillips  propose,  or 
silver  as  Olshausen  advises  for  support  in  prolapse,  or  large  catgut 
which  is  absorbed,  as  Terrier  and  Czerny  suggest  ?  Should  we  em- 
ploy a  Hodge  pessary  immediately  after  the  operation  (Leopold), 
tampon  the  vagina  when  the  case  is  one  of  retroversion  (Sanger),  or 
keep  the  patient  on  a  bed  which  is  inclined  toward  the  head  to  pre- 
vent intestinal  pressure  when  the  operation  has  been  done  for  pro- 
lapse (Phillips)  ?     These  are  points  of  detail  which  I  will  not  discuss. 

Prognosis  of  Gastro-hysteropexy. — The  published  results  give  but 
very  few  deaths.91  The  operation  is  not  more  fatal  than  an  uncompli- 
cated laparotomy.  There  is  no  doubt,  however,  that  the  prognosis 
may  be  aggravated  by  intra-abdominal  laceration  of  great  extent  i  as 
in  a  case  of  Klotz),  when  the  uterus  must  be  freed  from  strong  adhe- 
sions, and  in  particular  from  adhesion  of  its  surface  to  the  rectum. 
It  is  only  in  these  cases  that  drainage  is  indicated.  Experience  has 
proved  that  the  bladder  is  not  often  involved  and  that  there  is  seldom 
much  urinary  trouble.  The  results  appear  to  be  permanent.  Leo- 
pold 92  has  had  cures  lasting  three  years  and  Korn 93  sixteen  months, 
in  retroversions;  but  Olshausen  has  had  one  striking  failure  after 
ventro-lixation  for  prolapse.  In  one  of  Sanger's 94  patients  three  months 
after  operation  there  was  already  a  tendency  toward  return. 

A  question  which  it  is  very  important  to  answer  otherwise  than 
by  theoretical  considerations  is  concerning  the  influence  "which  preg- 
nancy might  have  on  a  uterus  sutured  to  the  abdominal  wall.  "Would 
the  adhesion  be  ruptured  ?  Would  the  course  of  the  pregnancy  be 
interfered  with  by  the  obstacle  produced  to  its  increase  in  size  ?  or 
would  such  increase  go  on  very  easily  above  and  outside  of  the  small 
surface  immobilized?  One  of  the  reasons  why  Olshausen,  Sanger, 
etc.,  have  adopted  the  suture  of  the  uterus  along  its  edges  rather  than 
on  its  anterior  surface  seems  to  be  just  this  fear  of  obstructing  the 
development  of  the  organ  during  gestation.  But  their  procedures 
assure  insufficient  adherence;  and  the  cleft  which  Olshausen  leaves 
between  the  bladder  and  the  uterus,  is,  in  spite  of  all  precautions,  a 
dangerous  point  for  the  production  of  internal  strangulation.  Experi- 
ence has  sustained  some  of  the  theoretic  objections  on  this  point. 
Sanger 95  performed  hysteropexy  on  a  woman  who  afterward  became 
pregnant  and  at  the  end  of  six  months  had  had  but  very  slight  pains ; 
Routier96  has  safely  delivered  one  of  his  patients  without  destruction 


468  CLINICAL   AND    OPERATIVE    GYNAECOLOGY. 

of  the  fixing  adhesions ;  while  Kiistner 97  has  described  two  abortions 
due  to  the  operation. 

Indications  for  Gastro-liysteropexy  in  Retroversion. — Should 
the  operation  be  performed  for  cases  where  the  nterns  is  movable, 
that  is  to  say,  the  displacement  reducible,  trusting  to  the  benign  char- 
acter of  antiseptic  laparatomy,  when  a  properly  selected  pessary,  with 
perseverance  on  the  part  of  the  physician  and  with  patience  on  the 
part  of  the  woman,  has  demonstrated  that  the  case  is  not  to  be  cured 
by  the  employment  of  such  an  instrument  and  that  the  symptoms 
persist  ?  It  seems  to  me,  it  should  not  be.  Shortening  of  the  round 
ligaments  is  too  valuable 93  a  resource  to  be  neglected  in  such  a  case. 
In  one  instance  Sanger  attempted  this  orjeration  before  doing  hyster- 
opexy, but  without  success ;  but  in  another  he  decided  upon  the  latter 
operation  from  the  first  without  attempting  to  maintain  the  uterus 
by  shortening  the  ligaments.  The  same  is  true  of  Leopold's  first  opera- 
tion. This  is  an  abuse  against  which  we  should  protest.  When  two 
operations  are  likely  to  give  the  same  result,  the  more  dangerous  should 
not  be  attempted  before  the  safer  has  been  tried  in  vain  {actum  mino- 
ris  periculi).  Now,  in  spite  of  the  progress  of  abdominal  surgery,  no 
one  pretends  that  opening  the  peritoneum  and  suturing  the  uterus  does 
not  endanger  the  patient's  life  more  than  a  superficial  incision  and 
suture  of  the  shortened  ligaments.  If  I  reject  gastro-hysteropexy  at 
the  outset  of  the  treatment  as  an  exaggeration  of  its  province,  yet, 
when  we  have  tried  Alexander's  operation  without  success,  I  think 
that  the  first  operation  is  legitimate ;  it  is  more  rational,  more  sure, 
and  perhaps  less  dangerous  than  the  vaginal  methods  of  hysteropexy, 
and  is  preferable  to  vaginal  extirpation  of  the  organ. 

The  principal  indication  for  abdominal  hysteropexy  seems  then  to 
be  found  in  those  cases  of  retroflexion  which  are  irreducible,  where 
there  are  adhesions  which  can  be  destroyed  only  under  chloroform, 
which  keep  the  fundus  always  in  Douglas'  pouch,  except  possibly 
after  a  false  reduction  where  the  uterus  is  replaced  by  drawing  with 
it  the  anterior  wall  of  the  rectum.  When,  with  the  patient  un- 
der an  anesthetic,  we  are  convinced  that  the  uterus  cannot  be  re- 
duced by  the  use  of  external  means  aided  by  the  sound  or  the  reposi- 
tor  within  the  organ ;  when,  especially  after  dilatation,  the  finger  in 
the  uterus,  as  Schnltze  advises,  is  not  able  to  effect  the  reduction — in 
such  cases  there  are  but  two  things  to  do ;  either  abstain  from  new 
attempts  to  reduce  the  organ,  which  cause  serious  accident  to  the 
adnexa  and  the  pelvic  peritoneum,  or,  if  the  intensity  of  the  symp- 


DISPLACEMENTS    OF   THE    UTERUS.  469 

toms  demand  it,  perform  laparatomy,  liberate  the  uterus,  and  then 
fix  it. 

So  far  I  have  considered  hysteropexy  only  as  a  principal  pro- 
cedure, decided  upon  from  the  outset  as  applicable  to  retroversion. 
If  its  advisability  in  this  case  is  doubtful,  the  same  is  not  true  as 
regards  its  performance  secondarily,  as  the  complement  of  another 


,    .     x    ..  ■  :s  ■■-. 


f 


Fig.  256. — Course  op  the  Round  Ligaments  as  Seen  Through  the  Transparent  Peritoneum  CWylie). 

operation.  When,  in  the  course  of  a  laparatomy  for  another  lesion, 
fibroma,  ovarian  cyst,  inflammation  of  the  adnexa,  etc.,  the  uterus  is 
found  to  be  displaced  backward,  as  so  often  happens,  the  indication 
is  to  profit  by  the  occasion  and  replace  it.     If  there  is  a  pedicle  at 


■■&■  ^em^^'n,    ? 


Fig.  257.— Hysteropexy;  Wylie's  Method.     Shortening  the  round  ligaments  by  intraperitoneal  fold. 

one's  disposal,  it  may  be  sutured  into  the  wound.  I  think,  however, 
that  it  is  not  well  to  stop  here,  but  to  render  the  proper  position  of 
the  organ  certain  by  passing  a  few  sutures  through  the  superficial 
layers  of  the  fundus  or  its  anterior  face,  in  the  median  line. 

Another  indication  for  hysteropexy,  secondarily  performed,  is 
found  in  those  cases  where  there  are  severe  pains  or  painful  reflexes 
dexoendent  upon  the  state  of  the  adnexa,  which  may  be  simply  pro- 


470  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

lapsed  (movable  retroflexion),  or  adherent  (resistant  or  irreducible  re- 
troflexion), or  involved  in  inflammation.  Sanger  and  Leopold  have 
combined  castration  with  hysteropexy  in  the  latter  case.  Hysteropexy 
alone  suffices  in  simple  prolapse  of  the  ovary,  thus  becoming  a  con- 
servative operation,  for  as  the  iDains  disappear  after  the  uterus  is  fixed, 
Battey's  operation  is  unnecessary. 

The  following  modifications  of  abdominal  hysteropexy  are  of  con- 
siderable interest,  although  they  seem  to  me  inferior  to  those  already 
mentioned. 

Shortening  the  Utero-sacral  Ligaments  by  the  Abdominal 
Method. — This  procedure,  proposed  by  Kelly,"  consists  in  passing  a 
suture  on  each  side  of  the  rectum  at  the  bottom  of  Douglas'  pouch 
from  within  out,  and  then  deeply  into  the  cervix  at  the  insertion  of 
the  utero-sacral  ligaments.     Frommel  has  performed  it  once.100 

Shortening  the  Round  Ligament  by  Intraperitoneal  Fold. — 
First  Gill  Wylie,101  and  then  Emil  Bode,loa  of  Dresden,  have  proposed 
this  operation.  The  procedure  has  been  employed  by  Wylie 103  in  a 
great  number  of  cases.  He  folds  and  sutures  the  round  ligament  at  its 
middle  part  and  at  a  certain  distance  from  the  uterus,  after  removing 
the  peritoneal  surface  of  the  ligament  by  scraping,  so  as  to  freshen  it 
and  permit  its  adhesion  to  the  portion  folded  (Fig.  256  and  257). 
Polk 104  unites  these  ligaments  in  a  letter  X  or  cross  from  above  the 
bladder,  and  provokes  the  formation  of  a  fold  which  is  internal,  and 
not  external,  as  in  Wylie's  method.  G.  Ruggi,105  of  Bologna,  has  also 
performed  a  complicated  operation  for  the  same  purpose  and  obtained 
good  results. 

Immediate  Abdominal  Hysteropexy,  without  Lapar  atomy. — The 
old  fear  of  the  peritoneum,  which  still  persists  to  a  certain  degree,  has 
caused  many  surgeons  to  avoid  opening  it;  and,  on  the  other  hand,  the 
possibility  of  replacing  a  retroflexed  uterus  in  such  a  way  that  its 
fundus  came  in  contact  with  the  anterior  abdominal  wall  a  long  time 
ago  gave  rise  to  the  idea  of  direct  anterior  fixation  without  lapara- 
tomy.  According  to  Emmet,106  Marion  Sims  first  conceived  this  idea, 
in  1859,  and  constructed  a  special  hollow  needle  to  pass  a  silver  suture, 
with  this  object ;  but  having  one  day  begun  the  operation,  he  had  not 
the  audacity  to  finish  it.  Caneva,107  more  than  twenty  years  afterward, 
proposed  abdominal  hysteropexy  for  prolapse  by  piercing  the  serous 
membrane  through  a  small  exposed  surface,  but  he  does  not  seem  to 
have  performed  it.  Kaltenbach,108  however,  has  employed  it  five 
times,  using  silver  sutures.     Kelly,109  still  more  boldly  but  without 


DISPLACEMENTS    OF   THE    UTERUS.  471 

permanent  success,  lias  three  times  sutured  the  uterus  to  the  abdo- 
men by  passing  two  or  three  horsehair  sutures  deeply  through  the  fun- 
dus of  the  organ  without  preliminary  incision ;  the  sutures  are  fastened 
by  a  shot,  and  removed  on  the  fifteenth  day.  Assaky  uo  proposed  this 
operation  and  furnished  Roux,  of  Lausanne,  the  opportunity  of  show- 
ing its  dangers  by  a  personal  case.  Having  begun  to  perf  orm  the  oper- 
ation, before  suturing  the  peritoneum,  which  nothing  seemed  to  sepa- 
rate from  the  uterus,  he  suddenly  decided  to  make  an  incision,  and 
found  under  the  serous  membrane  a  loop  of  very  thin  intestine  which 
he  must  have  punctured.  This  demonstrated  the  dangers  of  this  bril- 
liant but  blind  procedure. 

Vaginal  Hysterectomy. — This  operation  has  been  performed  by 
certain  surgeons  for  painful  and  rebellious  retroversions,111  but  it  can- 
not be  considered  justifiable  except  where  other  radical  means  have 
been  exhausted,  including  abdominal  hysteropexy. 

Choice  of  Operation  for  Retroflexion. — The  first  indication  in 
every  case  of  painful  retroflexion  is  to  find  the  exact  seat  of  the  in- 
flammation and  the  mobility  of  the  uterus. 

If  the  uterus  is  easily  replaceable,  it  is  probable  that  there  is  only  a 
mild  degree  of  metritis.  If  bimanual  examination  confirms  this  diag- 
nosis, the  inflammation  must  be  cured  before  everything  else ;  and 
therefore  the  treatment  of  catarrhal  or  chronic  painful  metritis  should 
be  at  once  begun.  The  curette  should  be  employed,  and  if  there  is  hy- 
perplasia the  cervix  resected.  I  have  many  times  observed  that  intra- 
vaginal  amputation  (Simon,  Schroder)  has  been  followed  by  sponta- 
neous reposition  of  the  uterus,  owing,  without  doubt,  to  the  involution 
which  succeeds  and  imparts  new  tone  to  the  organ.  The  same  fact  has 
been  noted  by  others,  and  it  explains  the  cases  falsely  attributed  to 
complicated  procedures  of  excision  and  suture  which  act,  not  upon  the 
deviation,  but  the  metritis. 

When  the  uterus  has  been  replaced,  any  tenderness  about  the  ad- 
nexa  should  be  treated.  Then  a  pessary  may  be  fitted,  or  preferably, 
a  permanent  reposition  secured  by  Alexander's  operation.  If  these 
measures  fail,  and  if  at  the  end  of  several  months  the  deviation  has 
been  reproduced  and  the  pains  have  returned,  we  are  then  author- 
ized to  perform  laparatomy.  Keith 113  followed  the  above  plan  in  one 
of  the  first  hysteropexies  deliberately  proposed  and  performed. 

There  is  a  class  of  movable  retro-deviations  to  which  Alexander's 
operation  is  especially  adapted.  In  the  higher  ranks  of  society,  we 
often  observe  women  with  a  delicate  nervous  organization,  who  have 


472  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

an  easily  reducible  displacement  with  no  inflammation  but  where  too 
great  mobility  of  the  uterus  seems  to  be  the  cause  of  all  the  symp- 
toms. The  uterus  takes  a  new  abnormal  position  after  it  has  been 
replaced  and  is  found  in  latero-version  or  flexion  or  even  in  antever- 
sion.  There  is  a  condition  of  abnormal  mobility  of  the  organ,  simi- 
lar to  that  of  certain  joints  with  great  laxity  of  the  ligaments,  as  de- 
scribed by  Gerdy.  The  pathological  state  which  results  is  character- 
ized by  nervous  reflexes  and  neurasthenia,  and  approaches  without 
being  easily  confounded  with  that  synthetized  by  Glenard m  under 
the  name  of  entero-ptosis.  In  such  patients  the  application  of  a  pes- 
sary gives  immense  benefit.115  Yet  Alexander's  operation  is  better. 
These  patients  should  also  wear  an  abdominal  supporter. 

There  remain  now  only  the  adherent  retroflexions.  Here  the  diag- 
nosis appears  to  me  to  be  of  the  greatest  importance.  I  can  almost 
agree  with  Wylie 116  that  in  nine  cases  out  of  tea,  the  adhesions  have 
resulted  from  a  coexistent  salpingitis.  It  is  dangerous,  therefore,  to 
make  repeated  attempts  at  reduction,  either  with  the  finger  introduced 
into  the  dilated  organ  or  with  sound  and  repositor.117  If,  after  a 
moderately  thorough  trial  under  chloroform,  reduction  cannot  be  ac- 
complished, I  abandon  it.  If  there  is  metritis,  I  limit  myself  to  the 
surgical  treatment  of  this  (curette  and  amputation  of  the  cervix),  with 
the  hope  that  the  pains  will  disappear  with  the  cure  of  the  inflamma- 
tion. If  there  is  serious  disease  of  the  tubes,  old  and  xaersistent,  I  per- 
form laparatomy. 

If  there  is  severe  and  persistent  pain  with  no  appreciable  tubal 
disease,  laparatomy,  which  is  always  exploratory  to  a  certain  degree 
in  such  cases,  may  be  performed,  when,  if  any  developing  lesion  of  the 
adnexa  (pyo-salpinx,  parenchymatous  salpingitis,  oophoritis,  sclero- 
cystic  degeneration  of  the  ovary,  etc.),  is  found,  the  diseased  organ 
should  be  removed. 

After  castration  on  both  sides  and  destruction  of  the  adhesions, 
the  uterus  will  frequently  return  to  a  normal  position.118  Strictly 
speaking,  the  operation  of  hysteropexy  could  then  be  dispensed  with, 
but  for  fear  that  it  may  again  be  displaced  posteriorly,  it  is  well  to 
suture  it  to  the  abdominal  wall. 

In  cases  where  the  retroversion  coincides  with  a  certain  degree  of 
general  enfeeblement  of  the  pelvic  floor  and  of  the  supports  of  the 
uterus,  marked  by  relaxation  of  the  vagina  and  the  gaping  vulva, 
the  patient  is  usually  a  multipara  in  whom  the  retroposition  consti- 
tutes the  first  stage  of  prolapse.     In  these  complex  cases  the  various 


DISPLACEMENTS    OF   THE   UTERUS.  473 

contributing  factors  must  be  eliminated  by  a  combination  of  operative 
measures;  the  metritis,  by  curetting  and  amputation  of  the  cervix; 
the  uterine  deviation,  by  shortening  the  round  ligaments  if  the  uterus 
is  movable,  and  by  abdominal  hysteropexy  if  it  is  adherent;  the  per- 
ineal  weakness,  by  colpo-perineorrhaphy.  Plastic  operations  on  the 
perineum  and  vagina  should  be  deferred  until  the  uterus  has  been 
fixed,  that  we  may  better  appreciate  the  amount  of  surface  which 
needs  to  be  denuded.119 

As  it  seems  to  me  unadvisable  to  devote  a  whole  chapter  to  the 
consideration  of  the  less  important  displacements  of  the  uterus,  I  will 
simply  enumerate  them. 

The  uterus,  from  the  pressure  of  a  tumor  posterior  to  it,  may 
be  pushed  directly  forward — anteposition ;  retro-uterine  hsematocele 
offers  a  striking  example  of  this  displacement,  which  is  invariably  an 
epiphenomenon. 

Retroposition  is  a  posterior  displacement  of  the  entire  organ  with- 
out any  change  in  the  long  axis.  This  follows  posterior  para-  or  peri- 
metritis, and  may  occasionally  be  observed  in  its  typical  and  uncom- 
plicated form ;  though  as  a  general  thing  it  is  usually  complicated  by 
an  anteflexion  (Fig.  219).  The  symptoms  observable  are  due  to  the 
inflammatory  adhesions,  and  treatment  should  be  directed  to  these 
alone. 

Upward  Displacement  of  the  Uterus  is  also  merely  a  symptom. 
Tumors  in  the  pouch  of  Douglas,  in  the  ligaments,  or  those  imprisoned 
in  the  pelvis  may  lift  the  organ  out  of  place ;  in  some  cases  it  seems 
to  be  upheld  and  prevented  from  returning  to  its  normal  position  by 
adhesions  formed  during  pregnancy.  In  all  cases  the  cervix  is 
elongated. 

BIBLIOGRAPHY. 

1.  Sanger  :  Obst.  Soc.  of  Leipsic,  November  17th,  1884.  Centr.  fur  Gyn.,  1885, 
p.  664. 

2.  LOhlein  :  Zeit.  f.  Geb.  und  Gryn.,  Band  viii.,  p.  102.  See  also  HundtS :  Amer. 
Jour.  Obst.,  October,  1881,  p.  789. 

3.  Tillaux:  Re'troflex.  Accident,  et  Instan.  de  FUter.,  etc.  Ann.  de  Gyn.,  Dec, 
1889,  p.  405. 

4.  Schultze:  Displacements  of  the  Uterus,  p.  259. 

5.  U.  Trfilat:  Des  Retrovers.  et  des  Retroflex.  Adherent.  Sem.  He'd.,  July  4th, 
1888. 

6.  Schroder  :  Mai.  des  Org.  Genit.  de  la  Femme,  French  trans.,  p.  174. 

7.  Chrobak  :  Berlin,  klin.  Woch.,  1879,  No.  1. 

8.  Kehrer :  Beitrage  zur  klin.  und  experim.  Geb.  und  Gyn.,  Band  ii.,  Heft  3, 
Giessen,  1887. 


474  CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 

9.  Sielki :  Centr.  f.  Gyn,  1888,  695. 

10.  Kiderlin :  Obst.  Soc  of  Hamburg,  April  2d,  1889.  Centr.  fur  Gyn.,  1890, 
p.  81. 

11.  Trelat :   Loc.  cit.  (5). 

12.  Poullet :  De  lTntervent.  Intra-uter.,  etc.,  Lyons,  1888.  Roland:  Du  Trait, 
des  Retro  vers.,  etc.     Lyons  Thesis,  1888. 

13.  The  advantages  of  this  position  appear  to  have  been  noticed  at  first  in 
America,  by  H.  F.  Campbell,  of  Augusta,  Georgia  :  Pneumat.  Self-replacement  of 
Uter.  Trans.  Amer.  Gyn.  Soc,  vol.  i.,  p.  193,  Boston,  1877.  In  Germany  by 
Solger:  Beitr.  zur  Geb.  und  Gyn.,  Berlin,  1875.  In  France  by  Courty,  Compt. 
Rend,  de  1' Assoc.  Fr.  pour  l'Avance.  des  Scien.,  Paris,  1881. 

14.  Tarnier  :  Preface  to  Bar's  French  trans,  of  Hegar  and  Kaltenbach  :  Traite 
de  Gyn.  Op6r.,  Paris,  1885. 

15.  E.  Mosher  :  Am.  Jour.  Obst.,  Oct.,  1887,  p.  1,028. 
16..  Ktistner :  Cent.  f.  Gyn.,  1882,  No.  28. 

17.  Schultze  :  Eine  neue  Meth.  der  Reposit.  hartnackig.  Retroflex.  Centr.  f. 
Gyn.,  1879,  No.  3.  Ueber  Diagnose  und  LOsung  Periton.  Adhasion.  Zeit.  f.  Geb. 
und  Gyn.,  Band  xiv.,  Heft  1,  1887.  Erich  :  Eleven  Cases  of  Retroflex.,  etc.,  Amer. 
Jour.  Obst,,  vol.  xiii.,  Oct.,  1880. 

18.  J.  A.  Miller  :  Am.  Jour.  Obst.,  vol.  xx.,  p.  146. 

19.  Olshausen  :  Klin.  Beitr.  zur  Gyn.,  Stuttgart,  1884.     Schroder:  Loc.  cit. 

20.  Fritsch :  Die  Krankh.  der  Frauen.  With  the  same  object,  Tarnier  has 
adapted  the  Hodge  pessary  by  adding  a  curved  transverse  bar  to  the  posterior 
concavity. 

21.  Lazarevitch  :  Coup  d'OSil  sur  les  Changements,  etc.,  Paris,  1862.  Cutter: 
Boston  Gyn.  Jour.,  vol.  v.,  p.  174.     Thomas:  Dis.  of  Women,  3d  edit.,  pp.  363  and  379. 

22.  Courty :  Traits  Prat,  des  Mai.  de  PUter.,  3d  edit.,  1881,  p.  705. 

23.  Sanger  :  Ueber  Behand.  der  Retroversio-flex.  Uteri.     Cent.  f.  Gyn.,  1885. 

24.  On  Nov.  17th,  1840,  Alquie  presented  a  memoir  to  the  Academy  of  Medicine 
•with  the  title  "Sur  une  Nouvelle  Meth.  pour  Trait,  les  diver.  Deplace.  de  la 
Matrice";  Bull,  de  FAcad.,  t.  vi.,  but  no  report  was  made  on  the  subject.  In  1850 
Aran  (Mai.  de  l'Uterus,  p.  1,039)  mentioned  Alquie's  procedure  and  said,  "  If  not 
impracticable,  its  execution  presents  serious  difficulties  and  dangers  such  that  one 
cannot  expressly  recommend  it."  Nothing  Avas  done  to  remove  the  discredit  into 
which  the  operation  had  fallen  before  it  had  even  been  performed,  for  Deneff e, 
who  attempted  it  at  Gand,  left  it  incomplete  (Presse  M6d.  Beige,  1885,  Sept.),  and 
Freund  in  Germany  merely  experimented  on  the  cadaver.  Alexander  performed 
his  first  operation  Dec.  14th,  1881,  and  published  the  case  in  the  Liverpool  Med. 
Jour.,  Jan.,  1883.  Adams  had  already  described  the  operation  in  the  Glasgow 
Med.  Jour.,  June,  1882,  but  his  first  operation  was  not  done  till  two  months  after 
Alexanders.     For  detailed  history  see  Manrique,  Paris  Thesis,  1886. 

25.  Brit.  Med.  Assoc,  June  10th,  1885.     Obstet,  Soc.  of  Edinb.,  May  25th,  1885. 

26.  Winckel :  Lehrbuch  der  Frauenk,  1886,  p.  363. 

27.  Doleris  and  Ricard  :  Union  Med.,  Nov.  24th,  1883.  Basing  their  opinion  on 
dissections  of  28  cadavers,  these  authors  state  that,  "starting  from  the  internal 
ring  there  exist,  properly  speaking,  only  indistinct  vestiges  of  the  round  ligaments: 
none  in  the  young  subject,  none  in  thin  women,  not  to  be  found,  if  they  exist,  in 
very  fat  subjects,  but  a  little  more  evident  in  certain  old  women  and  the  post- 
puerperal  period.'1  After  a  contradictory  note  of  P.  Beurnier  (Union  Med.,  Dec, 
1885)  these  same  authors  retracted  the  categorical  statements  of  their  first  memoir 
(Union  M6d.,  Dec.  29th,  1885).  Doleris  made  a  similar  communication  to  the  Obst. 
Soc.  of  Paris  (Nouv.  Arch.  d'Obst.,  1886,  p.  90)  and  since  then  has  become  one  of 
the  most  ardent  partisans  of  the  operation  which  he  at  first  declared  impracticable. 


DISPLACEMENTS   OF   THE   UTERUS.  475 

Doleris:  De  1'Oper.  du  Raccourcis.  des  Lig.  Rond.     Nouv.  Arch.  d'Obst.,  1886,  pp. 
10,  68,  158,  229,  and  Pathog.  et  Trait,  des  Deviat.  Uter.,  Ibid.,  1890,  p,  52. 

28.  Alexander  :  Brit.  Gyn.  Jour.,  Nov.,  1885. 

29.  F.  Imlach  :  Edin.  Med.  Jour.,  Apr.,  1885,  p.  915. 

30.  Terrillon  :  Bull,  de  la  Soc.  de  Chir.,  March,  1890. 

31.  C.  L.  E.  Beurnier  :  Ligaments  Ronds  de  l'Uter.,  Paris  Thesis,  1886,  p.  95. 

32.  Casati :  Racog.  Med.,  1887,  Nos.  5  to  8. 

33.  Dol6ris :  Nouv.  Arch.  d'Obst.  et  de  Gyn.,  Feb.  25th,  1889,  p.  49. 

34.  Segond  :  Bull.' Soc.  de  Chir.,  1889,  p.  268. 

35.  S.  Pozzi  :  Bull.  Soc.  de  Chir.,  1887,  p.  93.  Bouilly :  ibid.,  1887,  p.  134. 
Trelat :  Sem.  Med.,  July  4th,  1888,  and  Bull.  Soc.  de  Chir.,  1889,  p.  256.  Dol6ris  : 
Loc.  cit.  Schwartz  :  Bull.  Soc.  de  Chir.,  1889,  p.  241.  Terrillon  :  ibid.,  1889,  p.  278. 
Roux  :  Rev.  Med.  Suisse  Romande,  Nov.  20th,  1888. 

36.  Harrington  :  Boston  Med.  Jour.,  April,  1886. 

37.  W.  Gardner:  Australian  Med.  Jour.,  Oct.  15th,  1886,  analyzed  in  Cent.  f. 
Gyn.,  1887,  p.  227,  report  of  20  personal  cases  with  results  always  satisfactory. 

38.  Verhandl.  Deutsch.  Gesell.  f.  Gyn.,  Erst.  Cong.,  1886,  p.  252  (Zeiss,  Slavian- 
sky,  Kilstner,  Mund6,  Winckel). 

39.  Werth  :  Halle  Cong.  (Cent.  f.  Gyn.,  1888,  p.  291),  mentions  nine  successful 
cases  in  his  practice,  one  of  a  year  and  a  half,  the  other  of  a  year. 

40.  Ktistner  :  Ibid.,  p.  259. 

41.  S.  Keith  :  An  Unsuccessful  Case  of  Alexander's  Operation.  Edinb.  Obstet. 
Soc,  May  12th,  1886.     Brit.  Gyn.  Jour.,  vol.  ii.,  p.  408. 

42.  Tr61at  :  Loc.  cit.  (5). 

43.  Munde"  :  Am.  Jour.  Obstet.,  Nov.,  1888,  vol.  xxi. 

44.  Mund6  :  Am.  Jour.  Obstet.,  Nov.,  1889.  Sanger:  Arch.  f.  Gyn.,  Bd.  xxxii., 
Heft  3. 

45.  Polk :  Hysterorrhaphy  and  Alexander's  operation.  Am.  Jour.  Obstet., 
Dec,  1889,  p.  1,271. 

46.  Amussat :  Comptes  Rendus  de  l'Acad.  des  Seien.,  Feb.,  1850.  Philippeaux  : 
De  la  Cauteriz.,  Paris,  1865,  p.  557. 

47.  Courty :  Traite"  Prat,  des  Mai.,  etc.,  3d  edit.,  1881,  p.  654. 

48.  Richelot  :  Union  MeU,  1868,  Nos.  58  and  59. 

49.  By  ford  :  Jour.  Amer.  Med.  Assoc,  August  7th,  1886. 

50.  Doleris  :  Traite"  des  Flex.  Uter.     Gaz.  des  H6p.,  1888,  No.  3. 

51.  Skutsch  :  Discussion  at  Halle  Cong.     Cent.  f.  Gyn.,  1888,  p.  392. 

52.  Schilcking  :  Eine  neue  Meth.  der  Radicalheil.  der  Retroflex.  Uteri.  Centr. 
f.  Gyn.,  1888,  Nos.  12  and  42.  And  also,  Bemerk.  tiber  die  Meth.  der  Vag.  Fix.,  etc 
Cent.  f.  Gyn.,  1890,  No.  8.  He  declares  that  he  has  employed  his  procedure  in  62 
cases  ;  for  the  first  twenty,  thread'was  used,  twelve  cases  alone  cured  of  their  dis- 
placement ;  but  in  the.  42  cases  where  he  employed  a  better  technique  there  was 
no  failure.  Tampke  :  Zwei  Falle  v.  Retrofl.,  etc,  ibid.  Thiem :  Meet,  of  Germ. 
Natur.  at  Heidelberg,  Sept. ,  1889.  Centr.  f .  Gyn. ,  1889,  p.  735.  This  author  has  modi- 
fied Schucking's  operation  a  little,  with  success  in  36  cases,  which  are  too  recent 
to  prove  anything.  L5hlein,  ibid.,  in  the  discussion  said  that  he  had  observed  a 
patient  operated  on  by  Schiicking  in  whom  the  retroflexion  had  been  reproduced. 

53.  Rabenau:  Ueber  neue  operat.  Behandl.  der  Retroflex.  Berlin,  klin.  Woch., 
May  3d,  1886,  No.  18,  p.  284. 

54.  Schmidt :  Cent.  f.  Gyn.,  1888,  p.  685. 

55.  E.  Fraenkel :  Deut.  Med.  .Woch.,  1888,  Nos.  45  and  46. 

56.  Sanger :  Cent.  f.  Gyn.,  1888,  No.  2. 

57.  Richelot :  De  l'Hysteropexy  Vag.  Comptes  Rend,  du  4eme  Cong,  de  Chir., 
1889.     Bull,  de  la  Soc.  de  Chir.,  Dec  11th,  1889.     Union  MeU,  December  11th,  1889.- 


476  CLINICAL  AND   OPERATIVE   GYNAECOLOGY. 

L.  H.  Debayle  :  De  THysteropexy  Vag.,  Paris  Thesis,  1890.  Nicoletis  had  not  pub- 
lished anything  before  these  papers  ;  his  first  operation  was  done  on  the  cadaver 
in  1887  and  the  first  by  Richelot  on  the  living  patient,  June,  1889. 

58.  U.  Trelat  and  S.  Pozzi  :  Bull,  de  la  Soc.  de  Chir.,  1889,  pp.  771  and  772. 

59.  Pean:  Bull.  M6d.,  Feb.  27th,  1889. 

60.  Candela  and  Dumoret  :  Laparo-Hysteropexy,  etc.  Paris  Thesis,  1889,  p.  23. 
See  also  Nouv.  Arch.  d'Obst.,  June  23d,  1889,  p.  211. 

61.  Freund:  Third  Congr.  Germ.  Gyn.  Soc,  Freiburg,  July,  1889.  Cent.  f. 
G-yn.,  Iso.  30. 

62.  Schultze  :  Zeit.  f.  Geb.  und  Gyn.,  Bd.  xiv.,  Heft  1. 

63.  Sanger:  Cent,  f.  Gyn.,  1888,  No.  2. 

64.  Koeberle"  :  Retroversion  de  la  Matrice  Irreduc,  Constip.  Opiniatre,  etc. 
Bull,  de  la  Soc.  de  Chir.,  1877,  p.  64.  Schroder  :  Mai.  des  Org.  Gen.  de  la  Femme, 
French  ed.,  p.  181,  who  cites  this  operation  of  Koaberld's,  in  referring  to  Schetelig's 
article,  Centr.  f.  Wissen.,  June,  1869,  p.  417,  remarks,  "  Qu'il  ramena l'uterus  en  evant 
et  le  reunit  ainsi  qu'un  pedicle  de  kyste  ovarique  au  bord  inferieur  de  la  plaie; "  this 
is  an  error,  for  there  was  no  ovarian  cyst;  the  confusion  arises  from  the  word 
"  ovariotomy"  Avhich  Kceberle  uses. 

65.  Shns  :  British  Med.  Journal,  December  10th,  1887,  p.  840.  Courty:  Trait<5 
Prat,,  etc.,  3d  ed.,  1881,  p.  707;  in  describing  the  two  preceding  cases  he  renmrks, 
"  I  do  not  cite  these  operations  as  examples  to  imitate." 

66.  Schroder:  Berl.  klin.  Woch.,  1879,  No.  1. 

67.  L.  Tait  :  The  Pathol,  and  Treat,  of  Dis.  of  the  Ovar.,  3d  ed.,  pp.  94  and  96. 

68.  Hennig  (Leipsic),  cited  by  Sanger:  Centr.  f.  Gyn.,  1888,  No.  2. 

69.  Olshausen :  Ueber  Ventraloper.  bei  Lageanomalien.  59th  Naturforsch. 
Versamml.  zu  Berlin,  Sept.  20th,  1886,  analysis  in  Centr.  f.  Gyn.,  1886,  p.  667.  This 
has  been  published  complete  under  the  title  :  Yentraloperation  bei  Prolap.  und 
Retrovers.  Uteri.     Centr.  f.  Gyn.,  October  23d,  1886,  No.  43,  p.  698. 

70.  Session  of  September  20th,  1886.     Centr.  f.  Gyn.,  1886,  p.  685. 

71.  H.  A.  Kelly:  Hysterorrhaphy.  Amer.  Jour.  Obst,,  January,  1887,  vol.  xx., 
p.  33.  His  paper  was  read  before  the  Obst.  Soc.  of  Phila.  on  November  4thj  1886 
(Am.  Jour.  Obst.,  vol.  xx.,  p.  67);  but  it  was  not  published  till  January,  1887,  after 
numerous  additions  from  Olshausen's  memoir,  which  he  had  read  on  September 
20th,  1886,  and  published  in  Centr.  f.  Gyn.  for  October,  1886. 

72.  Sanger:  Ueber  operat.  Behand.  der  Retrovers.  Uter.  Centr.  f.  Gyn.,  1888, 
Nos.  2  and  3. 

73.  Klotz  :  Gyn.  Soc.  of  Dresden,  October  6th,  1887.  Centr.  fur  Gyn.,  1888,  No. 
1,  p.  11,  and  entire  in  Berlin,  klin.  Woch.,  1888,  No.  4.  For  the  discussion  between 
Klotz  and  Sanger  see  Centr.  f.  Gyn.,  1888,  Nos.  5  to  7. 

74.  Leopold  :  Ueber  die  Annahung  der  retroflekt.  Gebarmut.,  etc.  Centr.  f. 
Gyn.,  1888,  No.  11.     Communicated  to  Gyn.  Soc.  of  Dresden,  November  3d,  1887. 

75.  Kelly :   Hysterorrhaphy.     Amer.  Jour.  Med.  Sci.,  1888,  p.  468. 

76.  These  cases  are  actually  hysteropexies  and  could  be  included  in  the  same 
category  with  those  which  are  complementary,  done  in  the  course  of  another  opera- 
tion. 

77.  Phillips  :   On  Ventr.  Fixat.  of  the  Uter.,  etc.     Lancet,  October  20th,  1888. 

78.  Schauta:  Prag.  med.  Woch.,  1888,  No.  29;  analysis  in  Centr.  f.  Gyn.,  1888, 
No.  45. 

79.  Czerny:  Ueber  die  Vernahung  der  rtickwarts  gelag.  Gebarmut.  Beitrage 
zur  klin.  Chir.,  Bd.  iv.,  p.  164. 

80.  S.  Pozzi  :  Rapport  sur  une  Observ.  de  Picque\  Bull.  Soc.  Chir.,  Dec.  5th, 
1888,  p.  936.     Terrier :  Ibid.,  Nov.  28th,  1888,  p.  901. 

81.  For  the  operations  performed  in  France,  see  Bull.  Soc.  Chir.,  1889,  p.  46  et 


DISPLACEMENTS   OF   THE   UTERUS.  477 

eeq.  Terrier,  3  cases  for  retroversion;  Routier,  1  case;  Championniere,  2  cases ;  Polail- 
lon,  ibid.,  p.  60,  a  fatal  case  for  prolapse.  I  have  performed  hysteropexy  for  retro- 
version twice,  one  case  remaining  cured  after  more  than  a  year.  In  one  of  my  cases 
the  round  ligaments  had  been  shortened  a  few  months  before  by  a  skilled  operator 
without  result  (S.  Pozzi,  Annal.  de  Gym,  May,  1800).  Beside  the  works  already 
cited,  see:  Fritz  Reih :  Inaug.  Dissert.,  Jena,  1888  (case  of  Schultze).  Fraipon  : 
Annul.  Soc.  M<5dico-Chir.  of  Li6ge,  No.  3,  Mar.,  1880,  p.  114  (case  of  Winiwarter's). 
Terrier:  Hysteropexie  dans  le  Prolaps.  Uter.  Rcv.de  Chir.,  March  10th,  1889. 
Dumoret :  Laparo-Hysteropex.,  Paris  Thesis,  1880.  Doleris  :  Soc.  Obst.  et  Gyn. 
de  Paris,  April  11th,  1880,  in  Repert.  Univers.  d'Obst.  et  de  Gyn.,  1880.  Lee  :  The 
Value  of  Hysterorrhaphy,  etc.;  Am.  Jour.  Obst,,  Dec,  1889,  p.  1,249;  report  of  6 
operations,  4  complete  success,  1  failure,  1  too  recent.  KUstner  (Dorpat):  3d  Cong. 
German  Gynak.,  June,  1889  (Cent.  f.  Gyn.,  1880,  No.  32);  employs  hysteropexy  for 
adherent  retroflexions,  and  advises  the  use  of  the  thermo-cautery  to  divide  ad- 
hesions. Sanger,  ibid.,  has  performed  ventro-fixation  12  times,  7  after  castration, 
5  without  removal  of  adnexa  ;  no  retroversion  in  any  case.  Hegar,  ibid.,  has  done 
the  operation  once  ;  used  silk,  but  the  uterus  was  not  maintained  ;  not  a  partisan 
of  the  operation.  Leopold  :  Samml.  klin.  Vortrage,  No.  333,  1880  ;  9  operations 
and  some  of  his  patients  cured  after  two  years.  In  a  more  recent  communication 
(Gyn.  Soc.  of  Dresden,  July  4th,  1889,  and  Cent.  f.  Gyn.,  1890,  p.  185)  declares  that 
patients  are  still  well  after  three  years,  without  return.  Marschner  :  Cent.  f.  Gyn., 
1880,  No.  10,  p.  159,  had  one  failure  by  Leopold's  method.  Schramm  :  Cent.  f. 
Gyn.,  1890,  p.  185,  9  successful  cases.  Czerny  :  Beitrag.  zur  klin.  Chir.,  Bd.  iv., 
Heft  1,  4  hysteropexies  after  ablation  of  the  adnexa  and  destruction  of  the  ad- 
hesions. Zinsmeister  :  Obst,  and  Gyn.  Soc.  of  Vienna,  May  14th,  1889,  Cent.  f.  Gyn., 
1889,  p.  831,  operated  3  times  after  no  success  with  massage.  Lehotzky  :  ibid., 
reports  7  cases.  Slaviansky  :  Obst.  and  Gyn.  Soc.  of  St.  Petersburg,  Feb.  23d,  1880; 
Cent.  f.  Gyn.,  1880,  p.  834,  2  cases,  of  which  1  after  castration  ;  Leopold's  method. 
Veit :  Obst.  and  Gyn.  Soc.  of  Berlin,  Nov.  8th,  1889,  Ueber  die  Indications-Stellung 
der  Retroflexionstherap. ;  Cent.  f.  Gyn.,  1889,  No.  49,  p.  850.  Cohn,  ibid.,  reports 
4  cases  with  success ;  one  of  but  6  months  ;  employed  silk  and  attributed  early 
disunion  to  catgut.  Odebrecht,  ibid.,  4  cases  ;  Leopold's  method  ;  very  recent. 
Marcel  Baudouin  collected  in  an  important  paper  on  the  subject  more  than  200 
cases  of  laparo-hysteropexy  up  to  1800. 

82.  S.  Pozzi:  Bull,  de  la  Soc.  de  Chir.,  Nov.  11th,  1888.  Dumoret:  Paris 
Thesis,  1889,  p.  119. 

83.  Czerny  :  Beitr.  Chir.,  1888,  Bd.  iv.,  p.  184. 

84.  Muller  :  Corresp.  Blatt  Schweiz.  Acrzte,  1878,  Bd.  ii.,  p.  188. 

85.  Kaltenbach  :  Zeit,  f.  Geb.  und  Gyn.,  1878,  Bd.  ii.,  p.  188. 

86.  The  author  in  a  recent  article  on  hysteropexy  has  wrongly  considered  Polk's 
briefly  described  procedure  as  analogous  to  that  of  Klotz  (Trans.  Am.  Gyn.  Soc, 
Sept.,  1887  ;  Am.  Jour.  Obst.,  vol.  xx.,  p.  1,045).  In  his  paper,  "Should  the  Ovaries 
and  Tubes  be  sacrificed  in  every  Case  of  Salpingitis  ? "  Polk  remarks  that  when  the 
deviation  (backward)  was  due  to  the  action  of  the  adnexa,  "he  had  twice  at- 
tempted, after  detaching  adhesions,  to  work  a  cure  by  the  simple  action  of  a 
drainage  tube ;  but  that  his  results  were  inferior  to  those  obtained  by  Alexander's 
operation  in  the  same  cases."  Here  was  then  no  fixation  of  the  uterus  but  only  a 
reposition,  while  Klotz  carefully  sews  the  ovarian  or  tubal  pedicle  to  the  abdom- 
inal wall. 

87.  Kelly  :  Am.  Jour.  Med.  Sci.,  May,  1888,  p.  468.  New  York  Med.  Jour.,  Oct. 
5th,  1889,  p.  583. 

88.  Leopold  :  Cent.  f.  Gyn.,  1888,  No.  11,  et  ibid.,  1890,  p.  185. 

89.  Czerny  :  Beitrage  zur  kl.  Chir.,  Bd.  iv.,  Heft  1,  p.  179. 


478  CLINICAL    AXD    OPERATIVE    GYNAECOLOGY. 

90.  Dumoret :  Loc.  eit.  (60). 

91.  The  author,  who  analyzes  Lee's  paper  (Am.  Jour.  Med.  Sci.,  1889,  p.  216), 
cites  two  deaths,  one  immediate,  one  late,  after  gastro-hysteropexy  ;  they  do  not 
seem  to  have  been  published.  Polaillon  (Bull.  Soc.  Chir.,  1889,  p.  66)  reports  one 
death  after  operation  for  prolapse. 

92.  Leopold  :  Cent.  f.  Gym,  1890,  p.  185. 

93.  Korn :  Cent.  f.  Gym,  1888,  p.  11. 

94.  Sanger  :  Verhandl.  der  Deutsch.  Gesell.  f.  Gym,  2d  Congress,  1888,  p.  110. 

95.  Sanger:  Semaine  MeU,  June  19th,  1889,  p.  204. 

96.  Dumoret :  Du  Prolapse  Uterin,  etc.     Gaz.  des  H6pit.,  Nov.  30fh,  1889. 

97.  Kiistner :  Third  Cong.  Germ.  Gyn.  Soc,  Freiburg,  June,  1889.  Ann.de 
Gym,  Oct.,  1889,  p.  295. 

98.  Trelat :  Des  Retro  vers,  et  des  Retrofl.  adherents.  Sem.  Med.,  July  4th, 
1889. 

99.  KeUy :  Am.  Jour.  Med.  Sci.,  1888,  vol.  xcv.,  ]STo.  5,  p.  468.  Noble:  A  Sys- 
tem. Stretch,  for  Short.  Broad  and  Utero-sac.  Lig.  Atlanta  Med.  and  Surg.  Jour., 
1888-89,  vol.  v..  pp.  75-82. 

100.  Frommel:  Cong.  Germ.  Gyn.,  Freib.,  1889.  Cent.  f.  Gyn.,  1889,  No.  32. 
Leber  oper.  Behandl.  des  retr.  Uter.,  Cent.  f.  Gyn.,  1890,  No.  6.  Reports  a  case  of 
more  than  one  year's  standing. 

101.  G.  Wylie:  Surg.  Treat,  of  Retrovers.,  etc.  Am.  Jour.  Obst.,  May,  1889, 
vol.  xxii.,  p.  478. 

102.  E.  Bode  :  Gyn.  Soc.  of  Dresden.  June  6th,  1888.  Cent.  f.  Gyn..  1888,  No.  48. 
His  first  operation  on  May  10th,  1888  ;  Cent.  f.  Gyn..  1889,  No.  3.  Wylie  operated 
first  in  1886  ;   described  it  in  June  or  July,  1888,  in  the  Pittsburg  Review. 

103.  Wylie:  Am.  Jour.  Obst,,  May,  1888,  p.  478.  Am.  Jour.  Med.  Sci.,  1889, 
p.  325.     Medic.  Record.  Nov.  30th.  1889. 

104.  W.  Polk:  Observat.  on  Surg.  Treat.  Retrovers.,  etc.  Trans.  Am.  Gyn. 
Soc,  vol.  xiv..  1888,  Philadelphia.  A  very  short  analysis  of  this  paper  in  Am. 
Jour.  Obst,,  Oct.,  1889,  p.  1,066, 

105.  G.  Ruggi :  Sulla  Cura  Endo-Abdom.  de  Alcani  Spostam.  Uter.  Bollet.  d. 
Scienze  Med.  d.  Soc.  Medico-Chir.  d.  Bologna,  serie  vi..  vol.  xxii.,  Fasc.  1  and  2, 
1888.  Mieheli :  Riforma  Med.  Rome,  Jan.  8th  and  9th.  1889.  This  article  relating 
to  Ruggrs  procedure  analyzed  in  Rev.  Sci.  Med.,  Hayem,  July,  1889. 

106.  Emmet:  Trans.  Amer.  Gyn.  Soc,  Boston,  September,  1889.  Amer.  Jour. 
Obst.,  October,  1889.  p.  1,068. 

107.  Caneva  :    Gazetta  degli  Ospit.,  December  20th,  1882,  No.  102.  p.  810. 

108.  Kaltenbach :  Meet,  of  Germ.  Natur..  Heidelberg,  September  3d,  1889. 
Centr.  f.  Gyn.,  1889.  p.  731. 

109.  Kelly  :    Amer.  Jour.  Obst.,  October,  1887,  p.  1,068. 

110.  Assaky  :  Bull.  Soc.  Chir.,  Nov.  20th,  1889;  he  has  since  then  operated  with- 
out accident.      La  Clinica.   Bucharest.  No.  1.  1890. 

111.  Roux  :  Bull.  Soc.  Chir.,  Dec.  4th,  1889.  Richelot :  Union  Med.,  1886,  p.  101. 
Bouilly  :   Bull.  Soc.  Chir..  Oct.  24th.  1888. 

112.  Triare  :  Retr.  de  TUter. :  Guerison  par  TExcis.,  etc.  Gaz.  des  Hopit.,  May 
26th.  1889.     Quenu  :  Bull.  Soc.  Chir.,  1889,  p.  771. 

113.  Keith:  Ed.  Med.  Jour.,  July,  1886. 

114.  F.  Glenard:  NeurastmSn.  et  Enteroptose.  Sem.  M6d.,  May  19th,  1886,  p. 
211. 

115.  Terrier  :  Bull.  Soc.  Chir..  April  3d,  1889,  p.  277.  "  I  cannot  advise  pessaries, 
for  which  I  have  an  instinctive  horror."  Bouilly  :  ibid  ,  p.  293,  justly  opposed 
this  radical  opinion,  which  I  also  combated  (ibid.,  p.  295). 

116.  Wylie  :  Loc.  eit.  (101).  p.  482. 


DISPLACEMENTS    OF   THE   UTERUS.        .  -±79 

117.  Delbet:  Bull.  Soc.  Anat,,  1888,  p.  980.     Picqu<5:  Bull.  Soe.  Chir.,  1889,  p.  937. 

118.  Routier :  Bull.  Soc.  Chir.,  Jan.  16th,  1889. 

119.  The  necessity  of  combined  operations  in  this  class  of  case  has  been  very 
clearly  formulated  by  Doleris.  Gaz.  Med.,  Paris,  April,  1886  ;  Nouv.  Arch.  d'Obst., 
1886,  p.  350  ;  Mem.  de  la  Soc.  de  MeU,  Paris,  in  Union  MeU,  June  11th,  1887  ;  Mem. 
to  Americ.  Gyn.  Soc,  1887,  p.  488.  These  last  two  are  reproduced  in  Nouv. 
Arch.  d'Obst.  et  de  Gyn.,  Jan.  and  Feb.,  1890.  Munde'  :  The  Value  of  Alexander's 
Operation  ;  Am.  Jour.  Obst.,  Nov.,  1888,  vol.  xxi..  pp.  1,132  and  1,136.  This  author 
has  for  a  long  time  practised  combined  operations  and  remarks  that  to  do  plastic- 
operations  on  the  perineum  before  fixing  the  uterus  is  to  '"put  the  cart  before  the 
horse." 


CHAPTER  XIX. 

PROLAPSE  OF  THE  GENITAL  ORGANS. 

Following  Trelat's x  example,  I  include  under  one  head  prolapse 
of  the  uterus,  that  of  the  anterior  vaginal  wall  pulling  upon  the 
bladder  (cystocele)  and  of  the  posterior  wall  dragging  forward  the 
rectum  (rectocele).  These  several  displacements  have  been  artificially 
classified  as  separate,  but  in  reality  should  be  described  together, 
since  the  cases  when  they  occur  independently  of  each  other  are  quite 
exceptional.  The  etiology  and  the  treatment  of  these  lesions  also 
serve  to  give  them  absolute  clinical  identity.  Moreover,  hypertrophy 
and,  elongation  of  the  cervix  should  be  included  in  the  anatomy  and 
symptomatology  of  these  displacements. 

Etiology. — Hart2  very  wisely  compares  these  displacements  to 
hernia.  But  there  is  this  difference  between  them:  in  an  ordinary 
hernia,  the  parts  pushed  outward  by  intra-abdominal  pressure  are 
freely  movable  (intestines,  omentum),  while  in  a  uterine  prolapse  we 
have  to  do  with  organs  fixed  or  limited  in  situation  by  their  firm  at- 
tachments, and  which  consequently  when  displaced  are  likewise  dis- 
torted. This  is  the  chief  reason  for  the  hypertrophic  elongation  of  the 
cervix.  As  in  hernise,  however,  we  recognize  displacements  due  to 
violence  and  those  due  to  weakness.  The  first  follow  a  violent  effort 
of  some  kind,  which  is  either  sufficient  in  itself  to  cause  the  injury, 
or  which  is  injurious  because  of  predisposing  conditions.  A  fall  upon 
the  back,  an  epileptic  seizure,  a  violent  attack  of  coughing  have  all 
been  the  direct  cause  even  in  virgins  of  what  some  authorities  term 
acute  prolapsus.3  In  the  majority  of  cases,  however,  the  uterine 
supports  have  been  enfeebled  by  one  or  more  labors,  and  some  vio- 
lent strain  is  merely  the  determining  factor  of  the  prolapse.  Preg- 
nancy 4  is  often  a  predisposing  cause  of  this  displacement,  a  fact  which 
can  be  readily  understood  when  we  consider  the  changes  which  have 
taken  place  in  the  parts  surrounding  the  gravid  uterus.  All  the  liga- 
ments are  elongated  and  at  the  same  time  softened ;  intra-abdominal 
pressure  is  increased,  and  bears  with  more  than  the  usual  force  upon 
the  weak  points  of  the  pelvic  floor,  where  the  vagina  forms  a  line  of 


pkolap.se  of  the  genital  ougaxs.  481 

cleavage  which  seems  always  ready  to  give  way  under  increased 
strain. 

Whatever  may  have  been  said  to  the  contrary,5  rapture  of  the 
perineum  is  a  predisposing  cause  of  prolapses  uteri.  It  permits  of  a 
gaping  condition  of  the  vulva  which  admits  air  into  the  vagina,  sep- 
arating its  walls,  and  diminishing  the  support  offered  by  the  perineal 
floor.  It  has  been  asserted 6  [and  truly]  that  the  transversus  perinsei 
and  the  levator  ani  may  have  sustained  a  subcutaneous  laceration,  or 
may  have  been  paralyzed  during  labor,  without  giving  any  external 
evidence  of  the  injury.  The  relaxed  condition  of  the  peritoneum, 
which  has  been  stretched  by  the  gravid  uterus,  also  tends  to  favor  the 
prolapsus  induced  by  parturition. 

Shall  we  go  further  and  admit  the  existence  of  an  hereditary  con- 
genital predisposition 7  to  prolapse,  or  consider  the  predisposition  to 
be  simply  an  individual  peculiarity  due  to  the  weakness  of  the  sup- 
porting genital  apparatus? 8  The  latter  view  certainly  seems  reasona- 
ble, and  would  account  for  the  fact  that  the  same  cause  is  productive 
of  varying  results  in  different  individuals.  It  is  the  same  in  the  case 
of  hernia. 

Pathological  Anatomy. 

In  this  connection  it  is  absolutely  essential  to  observe  a  certain 
classification  of  the  disorders  under  consideration. 

1.  Prolapse  of  the  Vagina  alone  {Cystocele  and  Rectocele). — In 
the  great  majority  of  cases,  prolapse  of  the  vagina  rjrecedes  that  of  the 
uterus,  the  uterine  displacement  following  in  the  course  of  time  as  a 
result  of  the  downward  dragging.  The  condition  may  exist  for  a  while 
alone.  The  anterior  vaginal  wall  is  the  more  easily  displaced.  In 
women  who  have  borne  many  children  it  is  not  unusual  to  observe  a 
small  cystocele  when  the  bladder  is  full.  This  is,  however,  in  no  sense 
a  pathological  rmenomenon,  the  anterior  vaginal  wall  simply  exceeds 
the  posterior  in  length,  and,  providing  that  the  perineum  possess  a 
sufficient  degree  of  tonicity  to  support  it,  the  results  are  of  little  con- 
sequence. If,  however,  the  perineum  be  deficient  in  tone,  a  form 
of  vesical  hernia  follows,  as  the  posterior  wall  of  the  bladder  is  inti- 
mately associated  with  the  vagina  and  cannot  be  separated  from  it. 
This  vesical  protrusion  is  sometimes  more  apparent  than  real,  the 
protuberance  (compare  Figs.  258  and  260)  being  mainly  the  subinvo- 
luted  and  thickened  vaginal  wall.     The  posterior  vaginal  wall  soon 

31 


482 


CLINICAL    AND    OPERATIVE    GYNAECOLOGY. 


follows  tlie  anterior,  and  the  dilated  rectal  ponch  becomes  insinuated 
between  its  folds ;  though  as  the  intestinal  and  vaginal  walls  are  only 
loosely  connected,  rectocele  occurs  less  frequently  than   cystocele. 


i    \  ^HSiii 


Fig.  258.— Prolapse  of  Genital  Organs.    Procidentia  of  thickened  anterior  vaginal  wall;  slight  cysto 
cele  ;  persistence  of  posterior  cul-de-sac;  hypertrophy  of  middle  portion  of  cervix. 


When  both  are  present,  a  ringer  introduced  through  the  anus  can  be 
hooked  into  the  posterior  part  of  what  appears  at  the  vulva  as  a  va- 


Fig.  259.— Prolapse  of  Genital  Organs.  Proci- 
dentia of  anterior  vaginal  wall  with  cystocele,  and 
hypertrophic  elongation  of  the  middle  portion  of 
the  cervix  (Schroder).  The  posterior  cul-de-sac  is 
intact. 


B 

Fig.  260.— Prolapse  of  Genital  Organs.  Com- 
plete procidentia  of  vagina,  with  cystocele ;  no 
rectocele ;  hypertrophic  elongation  of  the  supra- 
vaginal portion  of  the  cervix ;  the  posterior  cul-de- 
sac  is  inverted. 


ginal  protrusion,  while  a  curved  catheter  can  easily  be  inserted  into  the 
cavity  of  the  cystocele.     We  have  then  a.  double-lobed  protrusion  into 


PEOLAPSE  OF  THE  GEXITAL  OEGAXS. 


483 


the  vagina  (the  lobes  being  usually  of  unequal  development),  which 
enlarges  and  becomes  tense  urjon  straining,  and  the  surfaces  of  which 
still  retain  the  folds  and  the  color  of  the  vagina.  Under  the  influence 
of  the  air  and  friction  it  thickens,  hardens,  and  sometimes  ulcerates. 
If  there  be  no  prolapse  of  the  bladder  (which  is  rare)  or  of  the  rectum 
(less  rare),  the  peritoneum  may  insinuate  itself  into,  and  greatly 
deepen,  the  anterior  and  posterior  culs-de-sac.  This  condition  presup- 
poses immobility  of  the  uterus  and  rlaccidity  of  the  serous  membrane, 
or  else  (according  to  Freund)  lack  of  development,  for,  in  the  foetus,  the 
folds  of  peritoneum  are  relatively  much  lower  down.  A  portion  of  the 
small  intestines  may  now  fall  to  the  front  or  back,  pushing  down  the 
vaginal  wall,  and  forming  what  have  been  called  hernise  or  vaginal 


Fig.  261.— Prolapse  of  Genital  Organs.    Complete  procidentia  of  thickened  vagina  ;   slight  cystocele ; 
posterior  cul-de-sac  obliterated  ;  hypertrophy  of  supra- va ginal  portion  of  cervix. 


enteroceles.  These  lesions  are  exceedingly  rare  in  their  occurrence, 
there  being  on  record  but  few  cases  of  vaginal  prolapse  with  an- 
terior enterocele,9  and  still  fewer  of  vaginal  prolapse  with  posterior 
enterocele. 10 

2.  Vaginal  and  Uterine  Prolapse  toith  Secondary  Hypertrophic 
Elongation  of  the  Cervix. — The  constant  dragging  of  a  prolapsed 
vagina  upon  its  attachments  to  the  cervix  soon  affect  the  uterus  itself. 
These  attachments  are  loosened  by  degrees,  and  finally  slip  down  in 
such  a  way  that  the  projection  of  the  cervix  completely  disappears, 
being  covered  by  the  portion  of  vaginal  wall  which  formerly  constituted 
the  culs-de-sac.  The  uterus  being  still  immovable,  and  the  vagina  con- 
tinuing to  drag  downward,  the  cervix,  which  is  now  entirely  supra- 
vaginal, gradually  elongates.    Occasionally  it  is  lengthened  without 


484 


CLIXICAL   AXD    OPERATIVE   GYjST/ECOLOGY. 


any  hypertrophy,  but  more  often  the  passive  congestion  and  the 
inflammation  in  the  prolapsed  organs  bring  about  a  hypertrophic  con- 
dition— this  hypertrophy  being  entirely  a  secondary  process.  The 
preliminary  disappearance  of  the  cervical  projection  is  what  marks  the 
beginning  of  this  process,  the  cervix  then  being  perceptible  to  palpa- 
tion as  a  cylindrical  column  in  the  centre  of  the  inverted  vagina. 


Fig.  262. — Prolapse  of  the  Uterus,  with  considerable  hypertrophic  elongation  of  the  cervix  ;  cystocele. 


If,  as  not  infrequently  occurs,  the  posterior  vaginal  wall  gives  way 
later  and  less  completely  than  the  anterior,  the  vaginal  procidentia 
will  be  in  front  only,  and  the  posterior  cavity  of  the  vagina  will  still 
remain;  a  finger  introduced  into  the  posterior  cul-de-sac  (Figs.  258 
and  259)  will  be  able  to  appreciate  the  fact  that  the  posterior  portion 
of  the  cervix  is  hypertrophied. 

This  somewhat  singular  condition  of  things  is  quite  accounted  for 
by  the  preceding  considerations,  although  Schroder  gives  a  more  elab- 
orate explanation.     He  thinks  it  due  to  the  fact  that  the  hypertrophy 


PROLAPSE    OF   TIIL    GENITAL    ORGANS. 


485 


begins  in  the  middle  portion  of  the  cervix,  intra-vaginal  posteriorly, 
supra-vaginal  anteriorly  (Fig.  264,  b,  b). 

3.  Prolapse  of  Vagina  and  Uterus  Resulting  from  a  Primary  Hy- 
pertro%)hic  Elongation  of  the  Supra-  Vaginal  Port  ion  of  the  Cervix. 
— This  condition  was  for  a  long  time  unrecognized,  and  is  still  dis- 
puted by  some  authorities  ( Virchow) ;  it  nevertheless  exists,  although 
it  is  of  less  frequent  occurrence  than  Huguier  supposed.  In  some 
virgins  with  firm  vagina  and  perineum  and  no  prolapse  of  the  uterus, 


Fig.  263. — Prolapse  of  the  Uterus.    Hypertrophic  elongation  of  the  cervix  ;  rectocele. 

an  inversion  of  the  upper  part  of  the  vagina  may  be  observed,  coex- 
istent with  a  supra-vaginal  hypertrophy  of  the  cervix.11  I  operated 
upon  such  a  case  when  with  my  lamented  preceptor  G-allard.  We  are 
forced  to  admit  that  the  initial  elongation  of  the  cervix  drags  upon 
the  vaginal  attachments,  yet,  although  the  starting-point  of  the  process 
is  always  the  cervical  hypertrophy,  later  the  roles  may  be  reversed,  and 
the  vaginal  procidentia  become  of  chief  importance,  in  its  turn  causing 
elongation  of  the  cervix.  The  position  of  the  intra- vaginal  cervix  will 
aid  in  determining  whether  this  condition  of  things  exists;  it  is  so 
often  lengthened  by  hypertrophy  that  if  we  find  it  in  normal  position 
we  may  be  quite  sure  that  the  vaginal  attachments  are  not  dragging 
upon  it.    This  influence  exerted  upon  prolapse  of  the  genitalia  by 


486 


CLINICAL   AND   OPERATIVE   GYNAECOLOGY 


hypertrophy  and  elongation  of  the  cervix  above  the  vaginal  attach- 
ment had  been  observed  and  remarked  npon  by  several  author- 
ities, bnt  was  given  no  special  prominence  until  Hugaier  published 
his  celebrated  treatise 12  upon  the  subject.  With  sovereign  ability  he 
demonstrated,  by  the  aid  of  clinical  and  anatomical  material,  the  fact 
that  in  the  great  majority  of  cases  downward  displacement  of  the 
uterus  has  been  wrongly  interpreted;  there  has  not  been  prolapsus 
or  falling  or  precipitation  of  the  uterus  in  its  entirety  out  of  the  ab- 
dominal cavity  through  the  vulvar  opening,  hernia-fashion,  but  rather 
a  lengthening  of  the  supra-vaginal  portion  of  the  cervix  which,  un- 
dergoing hypertrophy  and  being  unable  to  extend  into  the  abdomen, 
pushes  downward  into  the  vaginal  aperture,  dragging  after  it  the 


Fig.  264.— SuBprvisiONS  of  the  Cervix 
(Schrceder).  P,  peritoneum  ;  V,  bladder  ; 
a,  intra-vagina]  portion;  b,  middle  portion 
(intra- vaginal  posteriorly,  supra-vaginal  an- 
teriorly); c,  supra- vaginal  portion. 


Fig.  265.— Conoidal  Amputation  of  the  Cervix  (Hu- 
guier's  method).  Portion  of  cervix  thus  obtained  (trans- 
fixed by  a  sound).     Natural  size. 


vagina  and  neighboring  viscera,  which  are  more  or  less  closely  adher- 
ent. This  theory  advanced  by  Huguier  was  revolutionary  to  the  ideas 
previously  entertained,  which  held  that  the  prolapse  of  the  uterus 
was  the  last  step  in  its  downward  displacement,  this  being  divided 
into  three  degrees:  1st.  Simple  downward  displacement.  2d.  De. 
scent,  the  cervix  appearing  between  the  labia.  3d.  Prolapse  or  pre- 
cipitation, where  the  fundus  has  followed  the  cervix  and  is  entirely 
outside  of  the  vulva.13  According  to  Huguier,  this  order  of  progres- 
sion without  a  preceding  cervical  hypertrophy  is  very  exceptional, 
the  cervical  changes  constituting  the  initial  lesion  and  causing  the  real 
displacement  of  the  vagina  and  the  apparent  displacement  of  the 
uterus.  It  forms  the  point  of  chief  importance  in  the  condition  and 
to  it  should  the  treatment  be  directed.  Huguier  performed  conoidal 
amputation  of  the  cervix;  he  first  dissected  it  out  from  the  vesical 
and  rectal  attachments,  and  then  amputated  as  high  as  possible  (Fig. 


PROLAPSE  OP  THE  GEXITAL  ORGANS. 


481 


265).  I  have  frequently  performed  this  operation  and  found  it  valu- 
able. But  if  done  according  to  Huguier's  method,  without  approxi- 
mating and  fastening  the  mucous  membrane  by  sutures,  it  will  lead  to 
contractions,  of  small  importance  in  women  who  have  passed  the  men- 
opause, but  of  great  inconvenience  to  those  still  menstruating.  A 
proper  appreciation  of  the  value  of  Huguier's  theories  upon  this 
point  will  give  it  a  high  position,  without,  however,  rushing  to  the 
extreme  of  Gallard 14  and  others  who  undoubtedly  overestimated  it. 
From  an  anatomico-pathological  point  of  view,  he  established  the 


Fig.  266. — Prolapse  of  the  Uterus,  following  a  retroversion  ;  no  hypertrophy  of  the  cervix. 


fact  of  the  frequent  occurrence  of  a  hypertrophic  elongation  of  the 
supra-vaginal  portion  of  the  cervix,  in  prolapse  of  the  genital  organs. 
It  is  true  that  this  hypertrophy  is  not  invariably  the  primary 
manifestation  that  he  supposed.  It  is  in  fact  usually  the  secondary 
elongation  due  to  the  traction  exercised  by  the  prolapsed  vagina ; 
while  the  hypertrophy  is  the  result  of  venous  stasis  favoring  a  paren- 
chymatous cervical  endometritis.  Yet,  the  fact  remains,  that  it  had 
been  unrecognized,  and  to  him  belongs  the  credit  of  bringing  it  into 
notice,  and  of  calling  attention  to  and  causing  the  adoption  of  ampu- 
tation of  the  hypertrophied  cervix  as  a  method  of  treatment.  That  it 
is  of  less  value  than  he  at  first  supposed,  scarcely  detracts  from  the 
merits  of  his  discovery,  Avhen  we  recall  the  almost  constant  failure  of 
all  plastic  operations,  before  the  introduction  of  antiserjsis.     Amputa- 


4S8 


CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 


tion  of  the  cervix  still  holds  its  own  in  therapeutics  as  an  important 
preliminary  step  in  operation  for  prolapsus. 

What  is  the  nature  of  this  hypertrophy  of  the  cervix?  When  it 
follows  the  continuous  traction  of  a  prolapsed  vagina,  it  is  undoubt- 
edly an  inflammatory  process.  But  when  it  constitutes  the  first  step 
in  the  process,  what  is  its  origin?  Is  it  the  result  of  a  congenital  pre- 
disposition to  malformations,  manifested  only  when  the  organ  is  com- 
pletely developed  either  at  puberty  or  from  the  nutritive  activity 
called  into  play  by  pregnancy?  Is  it  the  indication  even,  in  the  latter 
case,  of  a  localized  cervical  endometritis,  as  Gallard  supposes?  Each 
of  these  factors  may  operate  singly  or  together.     The  histological 


Fig.  267. — Prolapse  of  the  Uterus  -with  Anteflexion  ;  it  is  no  longer  connected  with  bladder  and 
rectum  ;  these  organs  meet  above  the  uterus. 


examination  does  not  give  any  very  satisfactory  result.  Olivier 15  has 
given  a  resume  of  such  examinations  upon  cervices  Which  I  had  re- 
moved, according  to  Huguier's  process,  when  in  Gallard's  service.  He 
found  no  hypertrophy,  but  he  did  find  a  localized  arterio-sclerosis. 
The  sections  examined  were  similar  in  structure  to  those  of  a  uterus 
with  endometritis.  Moreover,  the  distinction  was  not  carefully 
observed  between  sections  taken  from  a  cervix  where  the  hypertro- 
phic elongation  was  a  secondary  process  and  those  where  it  was  pri- 
mary. Inflammatory  lesions  may  often  be  secondary,  for  every  pro- 
lapsed uterus  is  almost  certain  to  develop  a  catarrhal  endometritis. 

.£.  Prolapse  of  Uterus  and  Vagina  without  Hypertrophy  of  the  Cer- 
vix.— A  slight  sinking  of  the  uterus,  rendering  it  more  easily  acces- 
sible to  the  examining  finger,  and  deepening  the  vaginal  culs-de-sac,  is 
frequently  observed.     But  complete  prolapse  is  rare  because  of  the  re- 


PROLAPSE   OF   THE   GEXITAL    OEGAXS. 


489 


sistance  to  be  overcome.  (Bastien  and  Legendre 16  certainly  exagge- 
rated the  amount  of  resistance  encountered.  According  to  their  state- 
ments, it  takes  a  force  of  from  twenty  to  twenty -live  kilograms  [forty- 
four  to  fifty -five  pounds]  to  pull  the  cervix  to  the  vulva  upon  the 
cadaver,  and  of  over  fifty  kilograms  [one  hundred  pounds]  to  draw  it 
below  this  opening.  Daily  clinical  experience  proves  that  upon  the 
living  subject  this  same  thing  can  be  done  without  any  violent  exer- 
tion, but  owing  to  the  elasticity  of  the  tissues  the  organ  returns  to  its 
normal  position  as  soon  as  released.  In  a  pathological  condition 
this  elasticity  is  lost,  and  the  organ  remains  out  of  position.) 


Fig.  268. — Prolapse  op  the  Uterus  with  Retroflexion  ;  rectocele. 

It  may  be  termed  a  hernia  from  violence,  since  so  great  an  effort  is 
required  to  produce  it.  In  this  case  the  uterus  usually  drags  the 
vagina  after  it ;  the  organ  itself  is  usually  retroverted,  this  displace- 
ment rendering  the  occurrence  of  prolapse  more  probable  under  strain 
(Fig.  266).  After  the  uterus  has  emerged  beyond  the  vulvar  opening, 
it  may  undergo  deviations  from  its  normal  axis,  and,  suspended  in  its 
hernial  sac,  become  ante-  or  retroflexed  (Figs.  267,  268).  Inversion 
combined  with  prolapsus  has  also  been  observed. 

The  relations  of  the  neighboring  organs  vary  according  to  the  kind 
and  degree  of  the  displacement ;  as  a  general  rule,  the  greater  the 
cervical  hypertrophy  (and  by  cervix  we  here  mean  exclusively  the 
supra-vaginal  portion)  the  farther  are  the  folds  of  peritoneum  from 
the  uterine  orifice ;  on  the  other  hand,  in  the  variety  shown  in  Fig. 
266  they  would  be  very  near  to  it. 


490  CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 

With  a  marked  rectocele  (Fig.  268)  fecal  matters  tend  to  accumu- 
late and  harden  in  the  pouch. 

A  cystocele  usually  results  in  the  formation  of  a  wallet-shaped 
bladder,  whose  lower  pocket  is  situated  below  the  internal  urethral 
opening,  this  frequently  giving  rise  to  stagnation  of  the  urine  (Figs. 
259  and  266).  There  is  often  dilatation  of  the  bladder,  and  even  of 
the  ureters  and  the  rjelvis  and  calyces  of  the  kidney,  owing  to  the 
strain  upon  or  compression  of  the  lower  end  of  the  ureters.17  Calculi 
are  said  to  have  been  found  in  the  cystocele,  but  there  are  fewer  cases 
reported  than  the  theories  advanced  would  lead  one  to  expect.18 

The  vaginal  mucous  membrane  is  thickened,  often  resembling  skin 
or  leather,  and  becomes  blanched  or  violet-colored.  The  prolapsed 
portions  are  cedematous,  and  we  frequently  notice  ulceration  of  the 
cervix,  ectropion  of  the  os,  or  excoriations  and  ulcerations  due  to  fric- 
tion of  the  surface  of  the  tumor.  Endometritis  almost  always  occurs 
in  a  prolapsed  uterus,  and  salpingitis  is  not  infrequent. 

Symptoms. — Acute  prolapsus,  as  it  has  been  termed,  meaning  that 
which  immediately  follows  some  violent  strain,  is  rare,  yet  cases  have 
been  reported.  Immediately  after  the  accident,  a  tumor  formed  by 
the  anterior  wall  of  the  vagina  alone,  or  by  the  uterus  as  well,  is  seen 
hanging  out  of  the  vulva.  Intense  pain,  sometimes  syncope  and  peri- 
tonitis, accompany  the  lesion.  Usually,  however,  the  prolapse  is  grad- 
ual, and  gives  rise  to  no  well-marked  symptoms;  a  feeling  of  heavi- 
ness referred  to  the  perineum,  a  dragging  sensation  in  the  loins  and 
abdomen,  fatigue  upon  walking,  are  the  chief,  accompanied  by  the 
ordinary  symptoms  of  endometritis,  besides  troubles  connected  with 
micturition,  dysuria,  polyuria,  incontinence,  or  retention,  with  or  with- 
out cystitis.  If  there  be  a  very  large  cystocele,  the  patient  may  be 
obliged  to  assist  micturition  by  external  pressure  upon  the  protrud- 
ing bladder.  Menstruation  is  unaffected.  Fecundation  is  rare,  though 
possible,  in  complete  prolapsus.  Abortion  may  follow,  but,  again,  the 
gravid  uterus  may  develop  normally  in  the  abdomen,  casing  a  tem- 
porary disappearance  of  the  displacement. 

In  prolapsus,  as  in  hernia,  the  severity  of  the  rational  symptoms 
does  not  always  depend  upon  the  gravity  of  the  lesion.  Often  women 
apply  for  admission  to  the  hospital,  with  a  uterus  suspended  between 
the  thighs,  who  have,  in  despite  of  this  condition,  continued  to  per- 
form hard  manual  labor  with  apparent  ease,  until  some  accident 
obliges  them  to  stop  and  undergo  treatment.  On  the  other  hand,  some 
patients  whose  uterus  is  only  slightly  fallen,  and  is  not  even  near  the 


PROLAPSE  OF  THE  GENITAL  ORGANS.  491 

vulvar  opening,  complain  of  intense  pain  when  walking,  and  are  re- 
duced to  a  state  of  invalidism.  It  would  seem  as  if,  in  the  former 
case,  a  new  and  definite  static  condition  of  the  uterus  had  been  devel- 
oped, giving  tolerance  to  a  well-marked  lesion,  while  in  the  latter 
case  this  species  of  compensation  had  not  been  acquired;  the  unstable 
condition  of  the  uterus  giving  rise  to  numberless  twinges  of  pain,  and 
nervous  reflex  j)henomena,  which  make  a  prolapsus  uteri  one  of  the 
manifestations  of  "  entero-ptosis,"  that  group  of  symptoms  so  ably 
classified  by  Glenard.19 

The  physical  signs  are  very  characteristic.20  In  the  early  stages 
of  a  prolapse,  the  vaginal  mucous  membrane,  though  very  flaccid,  does 
not  appear  beyond  the  vulvar  opening  unless  the  patient  strains.  By 
placing  her  in  the  dorsal  position  and  bidding  her  bear  down,  one 
may  see  the  anterior  vaginal  wall  bulge  outward  by  a  sort  of  rotary 
motion,  forming  a  soft,  pinkish  tumor,  which  returns  in  place  with 
the  cessation  of  the  downward  straining. 

It  is  well  to  bear  in  mind  that  the  anterior  and  posterior  vaginal 
walls  are  normally  in  aj)position,  so  that  a  section  of  the  canal  in  a 
state  of  rest  would  be  well  represented  by  the  letter  H .  The  proci- 
dentia of  the  vagina  could  scarcely  be  cylindrical,  as  in  the  case  of 
the  rectum;  the  anterior  or  posterior  walls  simply  slip  down,  either 
singly  or  together.  This  first  degree  of  cystocele  soon  gives  place 
to  the  permanent  and  more  severe  form,  and  later  the  os  uteri  appears 
just  behind  it,  discharging  the  mucus  produced  by  the  cervical  ca- 
tarrh. If  the  posterior  vaginal  wall  be  involved,  the  os  seems  to  be  in 
the  centre  of  a  pyriform  tumor  which  opens  out  the  labia  minora, 
and  whose  surface  is  dry,  wrinkled,  darkened  by  exposure  to  the 
air,  and  occasionally,  in  addition  to  ulcerations  around  the  os,  suffers 
a  loss  of  substance  from  friction  and  lack  of  cleanliness.  A  furrow 
surrounds  the  tumor  at  the  base,  especially  near  the  fourchette.  The 
size  of  the  tumor  varies  from  that  of  an  egg  to  that  of  two  doubled 
fists  (Figs.  262  and  263). 

Palpation  will  give  different  results  according  to  whether  the 
uterus  shares  in  the  prolapse  or  not.  Everything  included  in  the 
vaginal  procidentia  is  soft  and  flabby.  Tension  and  elasticity  of  the 
cystocele  increase  when  the  bladder  is  full.  The  existence  of  an  en- 
terocele  (which  is  of  rare  occurrence)  is  shown  by  gurgling.  When 
the  uterus  is  prolapsed  without  any  cervical  hypertrophy,  the  body 
even  of  the  organ  may  be  felt  in  the  interior  of  the  presenting  tumor 
(Figs.  266,  267,  268).     But  in  the  typical  cases  described  of  prolapsus 


-±92  CLINICAL   AXD    OPERATIVE   GYNAECOLOGY. 

either  preceded  or  followed  by  hypertrophy  of  the  cervix,  only  this 
portion  of  the  litems  is  to  be  found  in  the  tumor  (Figs.  258,  259,  260 
261)  of  which  it  forms  the  axis.  It  is  more  or  less  thick  and  rigid 
according  to  circumstances,  imparting  to  the  hand  the  sensation  of  a 
cord,  or  of  an  elastic  cylinder;  by  bimanual  palpation  it  is  found  to  be 
continuous  with  the  body  of  the  uterus,  which  is  behind  the  pubic 
bone. 

The  insertion  of  the  uterine  sound  will  reveal  pathognomonic  signs 
in  the  case  of  cervical  elongation ;  it  passes  for  a  length  of  from  four 
to  eight  inches.  [A  curious  fact  often  noted  in  these  cases  of  cervical 
hypertrophy  is  the  apparent u  ductility  "  of  the  tissues,  a  uterus  which 
when  prolapsed  is  seven  or  eight  inches  in  depth  measuring  only 
about  four  when  fully  replaced.]  We  must  remember  that  in  aged 
women  there  may  be  obliteration  of  the  cervical  canal.  The  tumor  is 
perfectly  reducible  when  the  uterus  has  not  participated  in  the  pro- 
lapse; even  if  it  has  done  so,  it  may  be  reduced,  but  is  with  great 
difhculty  kept  in  position.  A  permanent  cure  is  almost  always  im- 
possible ;  the  firm  column  in  the  midst  of  the  tumor  formed  by  the 
hypertrophied  cervix  could  only  be  pushed  into  place  by  a  degree  of 
violence  that  might  be  the  cause  of  injury. 

The  exact  position  of  the  bladder  may  be  determined  by  the  use  of 
a  male  catheter,  which  is  introduced  with  the  tip  turned  downward. 
The  bladder  often  reaches  the  immediate  neighborhood  of  the  uterine 
orifice  (case  of  secondary  elongation  of  the  cervix  from  traction)  (Fig. 
260) ;  in  other  cases  the  os  uteri,  which  has  remained  normal,  causes  an- 
other and  sometimes  large  bulging  below  the  lower  extremity  of  the 
bladder  (primary  hypertrophic  elongation  of  the  supra-vaginal  por- 
tion of  the  cervix  (Figs.  261  and  262). 

Course  and  Prognosis. — The  course  of  the  disease  is  chronic  in 
its  nature,  and,  if  untreated,  results  in  a  complete  prolapsus.  In  some 
patients  this  descent  of  the  genital  organs  is  coexistent  with  other 
large  hernia?,  and  forms  a  pelvic  condition  quite  as  incurable  as  the 
abdominal  disembowelling.  Cases  have  been  referred  to21  where  a 
spontaneous  cure  followed  the  temporary  reduction  of  a  prolapsus, 
when  the  uterus  was  bound  down  by  adhesions  formed  by  peritonitis. 
These  cases  seem  to  me  to  need  confirmation. 

Diagnosis. — By  bimanual  palpation,  rectal  touch,  and  the  use  of 
the  uterine  sound  and  the  catheter,  we  may  distinguish  the  tumor 
which  emerges  through  the  vulvar  opening,  from  a  polypus  or  an  in- 
verted uterus.     The  chief  difficulty  consists  in  determining  precisely 


PROLAPSE  OF  THE  GENITAL  ORGANS.  493 

what  parts  have  shared  in  the  prolapsus,  and  to  what  extent  they 
have  altered,  whether  in  position,  form,  or  size.  A  male  catheter  in- 
troduced into  the  bladder  will  determine  the  boundaries  of  the  dis- 
placement; a  linger  hooked  into  the  rectum  will  appreciate  any  folds 
of  intestine  anteriorly;  while  the  hypertrophied  condition  of  the  cer- 
vix may  be  felt  by  means  of  palpation  and  the  uterine  sound.  The 
condition  of  the  peritoneal  culs-de-sac  it  is  impossible  to  tell,  except 
when  efforts  at  reduction  result  in  a  gurgling  sound  and  give  rise  to 
the  supposition  that  loops  of  intestine  are  to  the  front  and  behind 
the  prolapsed  uterus.  As  I  have  before  observed,  these  enteroceles 
are  of  rare  occurrence,  and  are  never  found  where  there  is  supra-vagi- 
nal hypertrophy  of  the  cervix.  In  this  case  the  peritoneum  is  far- 
ther away  from  the  vagina  than  in  the  normal  condition;  in  simjxle 
descent  without  cervical  hypertrophy  it  is,  on  the  contrary,  nearer  to 
the  vagina  (Fig.  266). 

Urethrocele  is  an  interesting  variety  of  vaginal  prolapse,  which 
may  almost  be  considered  a  special  form  of  cystocele;  Professor 
Duplay 22  has  published  an  important  treatise  upon  the  subject.  The 
tumor  is  formed  by  the  dilatation  of  the  urethra,  or  by  a  cavity  open- 
ing into  this  canal,  the  bladder  not  being  implicated.  A  tumor,  rarely 
larger  than  a  walnut,  appears  at  the  vulva,  and  is  situated  immedi- 
ately beneath  the  urethra,  ax3j)arently  in  the  meatus ;  straining  brings 
it  more  into  view.  It  is  only  by  a  careful  examination  that  we  are  able 
to  distinguish  it  from  cystocele ;  we  then  see  that  it  extends  only  a 
little  way  upward  and  is  not  connected  with  the '  bladder,  which  has 
no  tendency  to  prolapse.  The  catheter  passes  into  the  pouch  of  the 
urethrocele  and  then  into  the  bladder;  the  inferior  wall  of  the  urethra, 
which  is  deflected,  is  much  longer  than  the  anterior  wall,  which  has 
retained  its  normal  position.  The  urethro-vaginal  wall  is  sometimes 
greatly  thickened  and  sometimes  much  thinned.  It  is  doubtful 
whether  a  urethrocele,  by  continuing  to  dilate,  can  ever  pass  into  the 
bladder  and  become  a  cystocele. 

Treatment, — The  prophylaxis  of  prolapse  of  the  genital  organs 
consists  in  the  careful  conduct  of  labor  and  subsequent  rigid  observ- 
ance of  hygienic  laws.  Belts  and  pessaries  give  little  help ;  yet  we 
must  not  neglect  to  support  the  abdomen  by  a  well-constructed  band- 
age which  will  keep  the  intestines  from  bearing  down  with  their  full 
weight  upon  the  pelvic  organs. 

Pessaries  are  of  use  only  when  the  perineum  has  preserved  a  de- 
gree of  tonicity;  their  action  is  often  aided  by  a  perineal  pad  (Figs. 


494 


CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 


269  and  270).  Breisky 23  claims  good  results  from  an  egg-shaped  pes- 
sary which  is  held  sufficiently  in  place  by  the  narrow  vaginae  of  aged 
women.  Dumontpallier's  ring  pessary,  Hodge's  pessary,  Schultze's 
sled-runner  pessary,  the  "  giinblette "  pessary,  Gariel's  air  pessary, 
should  all  be  given  a  trial.     Zwanck- Schilling's  winged  pessary  is  well 


<S^ 


Fig.  269.— Perineal  Air-Cushion. 

known,  but  of  little  value  [and  so  dangerous  that  it  should  be  men- 
tioned only  that  it  may  be  avoided]. 

In  order  that  any  kind  of  pessary  be  of  use,  I  repeat  that  a  cer- 
tain degree  of  tonicity  in  the  perineum  is  essential,  and  a  somewhat 
small  vulvar  opening.  They  are  valuable  in  cases  of  cystocele,  but 
fail  when  the  uterus  takes  part  in  the  prolapse.  In  any  case,  they 
should  never  be  used  except  as  a  palliative  measure,  trusting  to  a 
radical  operation  for  cure. 

Nevertheless  if  the  rjatient  positively  refuses  surgical  aid,  or  if  it 
offer  but  small  chance  of  relief,  as  in  the  case  of  complete  prolapse  in 


Fig.  270. — Belt  with  Perineal  Pad 


Fig.  271.— Basin-Shaped  Pessary. 


enormously  stout  women,  with  pendulous  abdomen,  whose  vagina  and 
uterus  seem  to  have  lost  all  connection  with  the  pelvic  cavity,  the 
only  resource  seems  to  be  a  stem  pessary 24  supported  by  a  belt.  Very 
similar  varieties  have  been  devised  by  Scanzoni,  Courty,  and  Grand- 
collot  (Figs.  271  and  272).  The  Dumontpallier  pessary  may  be  fixed 
to  a  stem  which  has  an  abdominal  support,  but  the  ring  must  be  very 
unyielding  to  be  of  use.  Borgnet's  cork  pessary  recommends  itself, 
especially  for  hospital  use,  by  its  simplicity  of  construction,  its  solid- 


PHOLAPSE  OF  THE  GENITAL  OKGANS. 


495 


ity,  and  its  cheapness  (Fig.  273).  Whatever  the  pessary  used,  its 
insertion  should  be  preceded  by  a  reduction  of  the  prolapse,  and 
treatment  tending  to  diminish  the  congestion  of  the  parts.  If  there  be 
oedema  or  inflammation,  the  patient  should  be  kept  in  bed ;  frequent 
baths  and  prolonged  tepid  vaginal  injections  are  to  be  given,  tampons 
applied,  and  massage  administered.     As  soon   as   the  tissues  have 


Fig.  272.— The  Roser-Scanzoni  Pessary. 

lost  some  of  their  rigidity,  reduction  of  the  prolapse  is  attempted,  the 
patient  being  in  the  Sims  or  else  the  genu-pectoral  position,  both 
of  which  favor  the  entrance  of  air  into  the  vagina.  The  bladder  and 
rectum  must  be  empty.  If  much  difficulty  be  experienced  in  restor- 
ing the  prolapsed  organs  to  place,  it  is  better  to  wait  patiently,  and 
not  use  force. 

[Much  may  be  accomplished  in  the  prophylaxis  of  these  displace- 
ments by  the  avoidance  of  any  exertion  during  the  puerperium ;  con- 
finement to  bed  imtil  involution  is  well  under  way ;  the  avoidance  of 


Fig.  273.— Borgnet's  Pessary. 

constipation  or  the  use  of  clothing  which  compresses  the  waist,  and 
the  immediate  suture  of  perineal  lacerations.  Any  relaxation  of  the 
vaginal  tissue  should  be  treated  by  hot  astringent  injections.  Chronic 
cases  of  slight  degree  are  benefited  by  the  tonic  effect  of  the  hot 
douche  and  by  astringent  tamponade,  and  according  to  many  writers 
by  elevation  of  the  uterus  and  massage  by  Thure  Brandt's  method.  Pes- 
saries in  general  are  unsatisfactory,  as  stated  above,  though  many  cases 
of  cystocele  receive  great  benefit  and  relief  from  the  pessary  devised 
by  Gehrung  (Fig.  274).     This  instrument,  while  most  efficient,  needs  to 


496 


CLINICAL   AKD   OPEEATIVE   GYNCOLOGY. 


Fig.  274.— Gehrung's  Pessary  for 
Cystocele. 


be  carefully  fitted,  and  is  difficult  to  adjust  unless  fully  understood. 
As  it  sustains  a  considerable  weight,  it  must  be  watched  to  see  that 
its  superior  bar  does  not  cut  into  the  vaginal  wall.  It  is  inserted  as 
follows :  Place  the  pessary  on  a  table,  with  the  superior  arch  (8)  be- 
low and  the  inferior  (7)  above,  the  curves 
JR,  and  L  pointing  toward  you.  Take  the 
pessary  by  curve  L  with  the  right  hand 
and  insert  curve  R  into  the  vagina  to  the 
right  of  the  patient  until  three-fourths  of 
the  instrument  is  buried  within.  Then 
push  curve  L  toward  the  fourchette  and 
the  left  side  of  the  patient,  so  that  it  slips 
into  the  vagina  at  the  same  time  that  S 
turns  upward  in  front  of  the  uterus  and 
/under  the  pubic  arch.  The  curves  M  and 
L  should  rest  squarely  on  the  posterior  vaginal  wall,  while  S  and 
/  support  the  rectocele  between  the  uterus  and  symphysis.] 

Surgical  Treatment. — This  offers  so  much  chance  of  relief,  and  is 
attended  by  so  little  danger,  that  it  ought  to  be  much  preferred  to  the 
use  of  pessaries. 

The  various  methods  used  may  be  thus  classified: 

1.  Support  derived  from  the  vagina,  vulva,  or  perineum. 

2.  Uterus  raised  by  shortening  the  round  ligaments. 

3.  Uterus  sutured  to  neighboring  structures  (hysteropexy)  through 
the  vagina  or  by  means  of  a  laparatorny. 

4.  Hysterectomy. 

Before  going  into  the  details  of  these  various  operations,  we  must 
devote  a  few  moments  to  the  consideration  of  a  valuable  preliminary 
operation,  designed  to  favor  the  replacing  of  the  uterus  when  the  cer- 
vix is  hypertrophied,  viz.,  amputation  of  the  cervix.  Instead,  how- 
ever, of  following  Huguier's  method  without  reference  to  subsequent 
reunion,  we  should  always  try  to  bring  the  mucous  lining  together, 
after  the  excision  of  a  conoidal  portion  of  each  lip  (Fig.  275). 

We  may  avoid  wounding  the  bladder  by  introducing  a  male  cathe- 
ter into  it,  which  is  to  be  held  by  an  assistant,  and  which  will  serve 
as  a  guide ;  the  peritoneum  posteriorly  and  the  rectum  may  be  pre- 
served from  injury  by  keeping  the  cutting  edge  of  the  bistoury  con- 
stantly turned  toward  the  part  to  be  excised.  The  vaginal  mucous 
membrane  may  be  sutured  to  that  of  the  cervix,  but  in  order  to  ac- 
complish this  it  is  necessary  that  the  segment  of  the  cervix  removed 


PBOLAPSE  OF  THE  GENITAL  ORGANS. 


497 


be  not  too  large;  indeed,  it  is  not  needful  to  remove  more  than  a  small 
portion,  to  insure  the  result  aimed  at  (C.  Braun;. 

/.  Support  Derived  from  IntrowoagiTial  Parts. — The  great  ma- 
jority of  operations  for  the  cure  of  prolapsus  come  under  this  head.  I 
shall  merely  enumerate  those  no  longer  used,  reserving  a  detailed 
description  for  those,  whose  use  I  recommend.  (Sehucking's  method, 
and  those  of  Freund  and  Pean,  described  in  the  chapter  upon  Retro- 
flexion, are  equally  applicable  to  prolapsus.; 

Among  the  old  methods,  I  will  name  episiorrhaphy,25  or  suture  of 
the  labia  majora,  to  contract  the  vulvar  opening;  freshening  the  sur- 
face and  suturing  of  the  vulvar  opening; 26  iniibulation  by  means  of  a 
metallic  ring; 27  cauterization  of  the  vaginal  walls  with  various  caustic 
agents,2S  or  with  the  actual  cautery;29  all  detestable  methods,  that 


Fig.  275.— Uterine  Prolapse  ;  amputation  of  the  vaginal  portion  of  the   cervix.    1,  before  the  suture  : 
2,  after  the  suture  ;  a,  bladder  ;  b,  Douglas1  cul-de-sac. 

have  recently  been  recalled  to  our  notice.  I  have  the  same  opinion  of 
treatment  by  ligation.30  Franck 31  performs  an  operation  whose  object 
is  the  formation  in  the  vagina  of  a  vertical  fold,  projecting  anteriorly 
like  a  tampon.  He  dissects  up  the  vagina  almost  to  the  posterior  cul- 
de-sac,  and  with  buried  catgut  sutures  forms  the  spur-like  projection. 
This  is,  however,  not  the  only  result  of  this  operation,  which  is  a  spe- 
cies of  colpo-perineorrhaphy. 

Elytrorrhaphy  or  colporrhaphy,  the  excision  and  suturing  of  a 
portion  of  the  vaginal  wall,  was  first  introduced  by  Marshall  Hall.32 
His  operation,  although  incomplete,  served  as  the  starting-xDoint  for 
the  perfected  operations  of  colpo-perineorrhaphy  and  perineauxesis 
of  the  present  day,  which  follow  the  plan  of  procedure  initiated  by 
Simon, 33  who  was  the  first  to  realize  the  importance  of  freshening  a 
large  surface  of  the  perineum  as  well  as  of  the  vagina.  His  denuda- 
tion was  in  the  form  of  a  trapeze.  Colporrhaphy,  or  anterior  elytror- 
32 


498 


CLINICAL    AND    OPERATIVE    GYNECOLOGY. 


rhaphy,  was  first  done  by  Sims.34  Since  Simon's  day,  the  size  and 
shape  of  the  denudation  in  this  o|jeration  has  been  indefinitely  varied. 
I  shall  describe  only  the  methods  of  Hegar  and  A.  Martin,  and 
Doleris'  for  perineoplasty,  besides  Le  Fort's  operation  for  closure  of 
the  vagina. 

Colpo-perineorrliapliy  (Hegar's  method). — The  patient's  bowels  and 
bladder  are  to  be  evacuated,  and  she  is  to  be  thoroughly  washed,  after 
which  she  is  anaesthetized  and  placed  in  the  dorsal  position.    The 


Fig.  276.— Colpo-Perineorraphy  by  Hegar's  Method. 


extent  of  surface  to  be  denuded  is  determined  by  grasping  the  poste- 
rior wall  of  the  vagina  with  the  forceps  and  drawing  it  into  view.  In 
cases  of  minor  importance,  it  will  be  quite  sufficient  to  make  a  de- 
nudation in  the  shape  of  an  isosceles  triangle — about  two  inches  broad 
at  the  base  (which  is  at  the  fourchette)  and  about  two  inches  long. 
When  the  prolapsus  is  very  great,  we  may  add  from  a  quarter  to  half 
an  inch  to  these  measurements.  During  the  operation,  continuous 
irrigation  should  be  practised ;  the  stream  of  tepid  water  should  be 
slow,  and  should  consist  of  either  a  weak  antiseptic  solution  (car- 
bolic acid  lfc),  or  of  filtered  water  with  salt,  6 : 1,000. 


PEOLAPSE  OF  THE  GENITAL  ORGANS.  499 

One  assistant  will  administer  the  chloroform,  two  will  hold  the 
thighs  and  the  forceps,  while  a  third  will  hand  the  instruments. 

Retractors  are  of  small  nse  in  bringing  the  parts  to  be  denuded 
into  view.  A  blade  of  a  speculum  temporarily  pushes  up  the  anterior 
wall  of  the  vagina,  and  the  surgeon  grasps  the  posterior  wall  with 
tenaculum  forceps,  about  two  inches  above  the  f ourchette,  at  a  point 
which  is  to  constitute  the  apex  of  the  freshened  surface.  The  labia 
are  separated  and  two  forceps  placed  at  the  ends  of  the  base  of  the 
triangle  at  the  lower  extreme  inferior  limit  of  the  vagina  and  about 
two  inches  apart. 

Two  additional  forceps  mark  the  middle  of  the  sides  of  the  triangle. 
When  the  assistants  hold  out  all  these  forceps,  the  operating  field  is 
conveniently  spread  before  the  surgeon.  With  a  sharp-curved  bis- 
toury he  outlines  the  triangle,  making  the  base  slightly  concave,  and 
the  sides  very  sightly  convex  to  the  centre.  The  mucous  membrane 
is  now  grasped  at  the  apex  with  mouse-toothed  forceps,  and  dissected 
sufficiently  to  allow  of  the  finger  replacing  the  instrument,  strong 
traction  being  at  the  same  time  exerted  upon  the  detached  membrane 
to  facilitate  its  dissection.  If  the  recto- vaginal  septum  be  very  thin, 
it  is  well  to  avoid  the  danger  of  puncturing  it,  by  introducing  a  finger 
through  the  anus.  In  view  of  the  possibility  of  this  procedure,  the 
rectum  should  have  been  previously  subjected  to  a  thorough  cleans- 
ing with  boric  or  salicylic  acid  solutions ;  the  assistant  who  attends 
to  this  preparatory  measure  must  thoroughly  disinfect  himself  after 
its  application.  If  there  be  hemorrhage,  the  bleeding  points  are  to  be 
seized  with  forceps.  The  whole  thickness  of  the  mucous  membrane, 
which  has  often  undergone  hyperplasia,  is  to  be  stripped  off,  and  the 
surface  of  the  wound  is  to  be  made  thoroughly  smooth  with  curved 
scissors.  Perforation  of  Douglas'  cul-de-sac  has  not  infrequently  oc- 
curred during  this  operation.  Schauta 35  seized  the  opportunity  of- 
fered by  this  accidental  opening  to  draw  down  and  resect  the  peri- 
toneal cul-de-sac.  This  manoeuvre  is  somewhat  similar  to  Freund's 
operation,  which  I  have  described  on  p.  558. 

For  the  suture,  Hegar  uses  silver  wire,  which  he  introduces  under 
as  much  of  the  surface  of  the  wound  as  possible,  adding  a  few  super- 
ficial sutures  between  these  deeper  stitches. 

It  seems  to  me  preferable 36  to  use  the  continuous  buried  catgut 
suture. 

Oolpo-perineorrliapJiy  or  perineauxesis  (Martin's  method). — Mar- 
tin's chief  object  in  this  operation  is  to  save  the  posterior  column 


500 


CLINICAL   AND   OPERATIVE   GYNECOLOGY. 


of  tlie  vagina,  which  is  the  most  resistant  portion,  and  which  Freund 37 
first  pointed  out  as  a  part  to  be  carefully  handled  in  all  plastic  opera- 
tions. Besides  this,  the  denuded  portion,  while  quite  as  extensive  as  in 
Hegar's  operation,  instead  of  forming  one  continuous  surface,  consists 
of  several  segments  in  close  juxtaposition,  which  allows  of  more  ac- 
curate suturing  and  more  perfect  union. 

Having  taken  the  same  preliminary  measures  as  in  the  former 
operation,  Martin  grasps  the  posterior  wall  of  the  vagina,  just  below 


Fig.  277 


-Colpo-Perineorrhapht  by  Martin's  Method.    Bilateral  denudation  of  posterior  vaginal  wall. 
Continuous  suture  in  layers. 


the  cul-de-sac,  with  two  pairs  of  tenaculum  forceps,  which  forcibly 
stretch  it  so  that  the  vaginal  column  (columna  rugarum)  has  the  ap- 
pearance of  a  long,  projecting  fold.  An  incision  is  made  with  the 
bistoury  on  either  side,  and  two  narrow  lateral  strips  are  dissected 
off  as  far  as  a  finger's  breadth  above  the  fourchette.  Tenaculum  for- 
ceps are  applied  to  both  extremities  of  these  freshened  surfaces  to 
keep  the  operating  field  as  tense  as  possible.  These  two  small  wounds 
are  now  sewed  up  by  a  continuous  suture  in  layers  (Fig.  277),  the 
forceps  are  removed  and  the  first  step  in  the  operation,  double  lateral 


PROLAPSE  OF  THE  GENITAL  ORGANS. 


501 


elytrorrhaphy,  is  now  completed.     The  second  step,  perineorrhaphy 
remains  to  be  done. 

A  transverse  incision  is  made  at  the  muco-cntaneous  junction,  which 
intersects  the  column  of  the  vagina,  and  ascends  on  either  side  to 
about  half  the  extent  of  the  vaginal  opening  [to  the  inferior  caruncles]. 
From  the  extremities  of  this  incision  a  second  concentric  incision, 
f  ormino-  an  acute  angle  with  it,  intersects  the  lower  part  of  the  vertical 


Fig.  278.— Colpo-Perineorrhaphy  by  Martin's  Method,  Showing  Denuded  Surface.  1,  2,  Incisions 
by  the  side  of  the  posterior  vaginal  column  ;  3, 4,  Incision  upon  the  lateral  wall  of  the  vagina;  /,  Extrem- 
ity of  denuded  surface,  at  the  level  of  the  vulvar  opening;  A- A,  B-B,  a-a,  b-b,  c-c,  d-d,  /3-a-/3,  8-5,  -y-y,  indi- 
cate the  points  which  will  be  in  contact  after  the  suture. 


incisions  made  in  the  elytrorrhaphy.  The  result  is  a  semilunar 
transverse  strip  whose  concavity  is  turned  upward  in  a  condition  of 
rest  (Fig.  278),  but  which,  when  pulled  upon  at  its  ends,  becomes 
lozenge-shaped.  This  strip  is  now  denuded,  and  the  surface  reunited 
by  a  continuous  catgut  suture  in  layers  as  in  Fig.  279. 

Martin  uses  a  trowel-shaped  bistoury  for  the  dissection  of  these 
strips  of  membrane,  rolling  them  up  on  a  slender  staff  with  lateral  teeth 


502 


CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 


(rdteau).  It  seems  to  me  that  an  ordinary  curved  bistoury  and  long 
forceps  are  equally  good.  Bischoff 38  has  adopted  a  method  which, 
like  Martin's,  preserves  the  normal  condition  of  the  vaginal  column 
(Fig.  280).  Winckel 39  denudes  the  lower  third  of  the  vagina  for  about 
an  inch  above  the  remains  of  the  hymen,  and  laterally  to  1.5  inches 
from  the  meatus,  making  first  a  vertical  median  incision  and  separat- 
ing the  mucosa  so  as  to  form  lateral  flaps.     He  then  brings   the 


Fig.  279.— Colpo-Perineorrhapht  by  Martin's  Method.    Continuous  suture  in  layers,  of  the  denuded 
perineal  surface  (deep  layer  of  stitches). 


freshened  surfaces  into  apposition  vertically,  as  in  Martin's  operation, 
and  after  shortening  the  two  flaps  one  half,  sutures  them  so  that  they 
form  a  bridge  across  the  remainder  of  the  denudation. 

Colpo-perineoplasty  by  Flap- splitting  (Doleris' 40  method). — This 
is  an  ingenious  combination  of  Lawson-Tait's  flap-splitting,  Schroder's 
removal  of  the  mucous  membrane,  and  Emmet's  suture,  and  is  chiefly 
applicable  where  the  uterine  prolapse  is  only  slightly  marked,  but 
where  the  vulva  gapjes   so  widely  that  there  is   danger  of   vaginal 


PP0LAPSE  OF  THE  GENITAL  OPGANS. 


rM 


prolapse,  with  or  without  partial  laceration  of  the  perineum.  It 
strengthens  the  perineum  by  increasing  its  length  and  thickness, 
without  any  vaginal  suture,  and  is  rapidly  performed.  The  weak 
point  of  the  process  is  the  shortening  of  the  posterior  vaginal  wall, 
which  interferes  with  any  ascent  of  the  uterus,  and  thus  renders  it  of 
doubtful  utility  in  cases  of  marked  prolapse.  It  cannot  be  combined 
with  Alexander's  operation,  as  can  Hegar's  and  Martin's  methods. 
Moreover,  it  does  not  contract  the  vagina  itself,  but  only  the  vulvar 
orifice,  and  is  in  fact  merely  a  perineoplasty,  since  the  portion  of 
vagina  removed  is  very  small.     With  a  bistoury,  Doleris  makes  a  deep 


Fig.  280.— Colpo-Perineorrhaphy  by  Bischoff's  Method. 


curved  incision  at  the  juncture  of  skin  and  mucous  membrane.  For- 
ceps are  inserted  at  the  two  ends  of  the  incision,  to  stretch  the  tissues. 
The  upper,  mucous  lip  of  the  wound  is  dissected  slightly  from  the 
submucous  tissue,  and  then  uplifted  by  forceps.  The  operator,  now 
using  the  index  finger  of  the  left  hand  instead  of  an  instrument, 
gently  pushes  the  tissues  apart,  separating  the  vaginal  and  rectal 
walls  as  far  as  necessary.  The  vaginal  flap  is  now  drawn  outside  of 
the  vulva  and  resected,  and  its  edge  then  united  to  the  edge  of  the  first 
incision  with  curved  needles  and  three  strands  of  heavy  silkworm 
gut.  The  first  stitch  is  in  the  centre ;  it  is  inserted  just  to  the  left  of 
the  anus,  goes  deeply  through  the  tissues,  and  into  the  vaginal  flap 
close  to  the  wall,  entering  the  vagina  or  not  as  the  operator  pref ers ; 


504 


CLINICAL   AND    OPERATIVE    GYnSTYECOLO&Y. 


it  is  then  brought  back  in  the  same  manner  to  the  right  side.  This 
first  suture  brings  the  vaginal  wall  near  the  vulvar  commissure,  also 
serving  to  unite  the  cutaneous  lips  of  the  wound.  The  second  and 
third  sutures  are  inserted  in  the  same  way,  each  slightly  outside  the 
other.  The  portion  of  the  flap  in  excess  of  the  reconstructed  f  ourchette 
is  now  cut  off,  and  the  mucous  and  cutaneous  lips  united. 

While  colpo-perineorrhaphy  is  the  chief  operation  for  prolapse  of 
the  genital  organs,  it  needs  often  to  be  supplemented  by  other  opera- 


Fig.  281.— Colpo-Pertneoplasty  by  Flap-Split-  Fig.  283.  — Colpo-Perineoplasty  by  Flap-Split- 
ting (Glissement).  Doleris' method.  Semicircular  ting.  Dissection  of  vaginal  flap,  A,  B,  D,  by  bistoury 
incision  following  the  outline  of  the  posterior  vulvar  and.  fingers.  Insertion  of  three  stitches  which  are  to 
commissure,  atthepointof  union  of  skin  and'mucous  bring  the  under  surface  of  the  flap  into  apposition 
membrane,  from  A  to  B.  with  the  cutaneous  lip  of  the  wound. 


ticns,  as  amputation  of  the  cervix,  already  described,  and  anterior  col- 
porrhaphy  or  elytrorrhaphy.  The  object  of  the  first  is  to  facilitate 
the  restoration  of  the  uterus,  while  the  latter  acts  directly  npon  the 
procidentia  of  the  anterior  wall.  Anterior  elytrorrhaphy  was  per- 
formed by  Sims,  whose  denudation  was  in  the  shape  of  a  horseshoe, 
with  its  convexity  toward  the  urethra.  Emmet  made  it  trowel- 
shaped.  Hegar  advises  an  ellipse,  with  as  blunt  an  upper  end  as  pos- 
sible. As  a  rule,  it  is  folly  to  waste  time  in  trying  to  obtain  a  flap  of 
any  special  shape :  the  exuberant  portion  of  the  vagina  is  simply  to 


PEOLAPSE  OF  THE  GENITAL  ORGANS. 


505 


be  excised.     I  lind  it  convenient  to'  take  up  a  fold  of  mucous  niem- 


Fig.   283.— Colpo-Perineoplast  by  Flap-Splitting.     Stitches  drawn.    The  flap  A.  R,  D,  lifted;   to  be 

^sected  on  the  line  A  to  B. 


Fig.  284.— Colpo-Perineoplasty  by  Flap-Split-  Fig.  285.— Colpo-Perineoplasty  by  Flap-Split- 

ting.   The  flap  has  been  excised  ;  two  lateral  open-       ting.    Suture  completed.    Stitches  all  ou  external 
ings  are  still  unsutured.  surface. 

brane  with  two  or  three  tenaculum  forceps,  the  highest  placed  about  an 
inch  from  the  cervix,  and  the  lowest  1.5  inches  from  the  meatus.     A 


506 


CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 


pair  of  strong  and  long  curved  forceps,  or  if  necessary  two  pairs 
(Fig.  286),  are  now  placed  upon  the  fold  [care  being  taken  to  avoid  in- 
clusion of  the  vesical  wall] ;  the  bladder  will  not  be  injured  by  even 
very  strong  traction.  Hegar  places  silver-wire  sutures  below  the' for- 
ceps (or  clamp)  before  exsection  of  the  vaginal  fold.  I  prefer  a 
continuous  suture  in  layers.     I  cut  off  the  mucous  fold,  stretch  the 


Fig.  286.— Anterior  Elytrorrhaphy.    Forceps  grasping  a  fold  of  vaginal  mucous  membrane. 


tissues  by  means  of  forceps  (Fig.  287),  and  insert  the  sutures  accord- 
ing to  the  method  described  on  page  49. 

Stolz 41  has  devised  a  very  ingenious  method  of  suturing  in  anterior 
colporrhaphy.  After  freshening  an  oval  surface  similar  to  that  shown 
in  Fig.  287,  two  curved  needles  are  threaded  on  a  silk  suture,  one 
needle  at  each  end,  and  beginning  near  the  cervix  the  suture  is 
passed  in  and  out  of  the  whole  circumference  of  the  wound,  about 
half  an  inch  from  the  edge  something  like  the  draw-string  of  a  tobacco 


PROLAPSE  OF  THE  GENITAL  ORGANS.  507 

pouch  (Fig.  288).  The  denuded  surface  is  pushed  inward  toward  the 
bladder  and  the  ends  of  the  silk  closely  drawn  and  tied.  Tins  was  the 
most  expeditious  procedure  known  before  the  use  of  the  continuous 
suture  in  layers,  which  should  be  given  the  preference.  Stolz  freshens 
the  anterior  vaginal  wall  with    curved  scissors,  after  rendering  it 


Fig.  287.— Anterior  Elytrorrhaphy.  Flap  removed.  The  raw  surface,  stretched  out  by  forceps,  is  to 
be  united  by  a  continuous  suture  in  layers.  At  the  lower  part  of  the  picture  is  the  bundle  of  stitches 
from  the  suture  of  the  amputated  cervix. 

prominent  by  the  pressure  of  a  thick  sound  introduced  into  the 
bladder. 

Closure  of  the  Vagina  (L.  le  Fort's  method). — Le  Fort42  calls  at- 
tention to  the  fact  that  the  prolapse  of  the  uterus  is  almost  always 
preceded  by  that  of  the  vagina,  the  walls  of  which  fall,  as  it  were,  from 
a  straightening  out  of  their  folds.     If,  he  reasoned,  these  walls  which 


508 


CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 


face  each  other  could  be  joined  together,  all  prolapse  would  be  pre- 
vented. The  next  step  was  the  uniting  of  the  walls  by  suture  after 
freshening  a  longitudinal  strip  on  each  (Figs.  289  and  290). 

Sometimes  the  prolapsed  uterus  becomes  so  enlarged  that  it  is 
difficult  to  restore  it  to  place  at  once.  That  the  reduction  of  the  dis- 
placement may  be  effected  by  degrees,  the  patient  is  kept  in  bed  from 
eight  to  fifteen  days,  after  which  the  passive  congestion  has  subsided 
in  whole  or  in  part,  and  the  uterus  is  diminished  in  size.  By  strain- 
ing, it  is  made  to  emerge  again  from  the  vulva. 

TJ 


Fig.  288.— Stoltz's  "Tobacco  Pouch"  Operation  for  Cystocele  (Munde).    C,  cervix;  U,  Urethra. 


The  freshened  surface  should  begin  as  near  to  the  vulva  as  possi- 
ble, since  it  is  in  this  situation  that  the  anterior  and  posterior  walls 
tend  to  separate  most  widely  and  thus  permit  of  a  prolapse.  If  one 
operates  too  near  the  cervix,  it  may  be  difficult  to  approximate  the 
surfaces  on  account  of  the  size  of  the  uterus.  As  a  usual  thing,  the 
surgeon  first  replaces  the  uterus,  opens  out  the  vulva,  and  with  a 
bistoury  makes  two  transverse  incisions,  one  upon  the  anterior  and 
the  other  upon  the  posterior  wall  of  the  vagina,  at  the  lowest  point 
where  these  two  walls  meet  (the  uterus  being  in  place).  These  two  in- 
cisions form  the  lower  borders  of  the  two  denuded  surfaces. 

The  vertical  length  of  the  freshened  surface  is  from  2.1  to  2.5 
inches,  the  vaginal  walls  having  been  unfolded  and  stretched  by  the 
prolapse  of  the  uterus  which  was  induced  by  straining  just  before  the 
operation.     The  breadth  of  the  freshened  surface  first  advised  by  Le 


PROLAPSE  OF  THE  GENITAL  ORGANS. 


509 


Fort  was  from  a  half  an  inch  to  three-quarters  of  an  inch.  At  the 
present  time  he  makes  it  about  an  inch  wide.  If  the  surface  be  too 
large,  it  will  interfere  with  perfect  union.  The  tissue  taken  off  should 
be  as  thin  as  is  compatible  with  the  exposure  of  a  raw  surface.  The 
removal  of  the  whole  thickness  of  the  vaginal  portion  of  the  posterior 
wall  would  endanger  the  cul-de-sac.  Tillaux  perforated  it  once,  and 
the  patient  died  of  peritonitis,  but  Le  Fort  thinks  this  the  only  time 
that  such  an  accident  has  occurred.  He  usually  begins  by  making 
four  incisions  to  outline  the  flaps  and  thus  facilitate  their  dissection. 


Fig.  289. — Le  Fort's  Operation  for  Closure 
op  Vagina.  R,  rectum ;  U,  uterus  ;  ur,  urethra ; 
A.  anterior  denudation  ;  B,  Posterior  denuda- 
tion. 


Fig.  290. — Le  Fort's  Operation  for  Closure  of  the 
Vagina.  A,  denuded  surface  upon  the  anterior  wall  of 
the  vagina ;  B,  denuded  surface  upon  the  posterior 
wall  of  the  vagina;  C,  C",  a  suture  on  the  leftside;  D,  D', 
suture  on  the  right  side. 


In  the  early  days  of  the  operation,  Le  Fort  used  silver  wire  for  the 
suture;  and  although  it  is  difficult  to  find  the  stitches  afterward,  even 
when  the  ends  are  long  enough  to  hang  outside  the  vulva,  he  still  uses 
them,  for  he  had  two  failures  with  silk  which  irritated  and  inflamed 
the  tissues.  He  several  times  tried  the  experiment  of  passing  the 
sutures  only  through  the  edges  of  the  wound,  but  met  with  small  suc- 
cess ;  in  such  a  case,  if  the  freshened  surface  be  of  any  size,  the  central 
portion  does  not  unite,  blood  collects  in  it,  and  the  operation  is  a  fail- 
ure. It  is  now  his  custom  to  pass  the  sutures  to  the  very  centre  of  the 
denudation.  The  first  one  is  inserted  at  the  middle  portion  of  the  end 
of  the  denuded  surface  nearest  to  the  uterus,  this  stitch  serving  as  the 


510  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

support  to  the  prolapsed  uterus.  Wheu  the  surfaces  A  B  are  once  in 
apposition  from  the  return  of  the  uterus  to  its  normal  position,  all 
that  remains  to  be  done  is  to  suture  the  edges.  The  needle  is  inserted 
into  the  mucous  membrane  of  one  of  the  vaginal  walls,  traverses  the 
wound,  and  enters  into  the  other  denuded  surface,  emerging  at  the 
mucous  membrane  of  the  opposite  vaginal  wall.  The  sutures  are  left 
in  place  two  weeks,  or  even  three  weeks  at  times,  and  no  attempt  is 
made  to  remove  them  until  certain  perfect  union  has  been  secured. 
No  dressings  are  necessary. 

Out  of  forty  operations,  Andre43  records  thirty-five  successful 
results,  of  which  thirty-one  were  successful  immediately.  It  is  an 
interesting  fact  that  this  operation  does  not  interfere  with  coi- 
tion, fecundation,  or  labor.  One  of  the  first  patients  upon  whom 
Le  Fort  performed  this  operation  went  through  a  perfectly  normal 
labor.  To  deliver  the.  child,  it  was  only  necessary  to  cut  the  artificial 
frenum  with  the  scissors. 

After-treatment  of  Colpo-perineorrTiapJiy. — The  care  of  the  pa- 
tients, after  these  plastic  operations  for  strengthening  the  perineum 
and  narrowing  the  vagina,  has  an  important  bearing  upon  primary 
union ;  should  this  primary  union  fail,  the  success  of  the  operation 
will  be  endangered,  in  spite  of  cases  quoted  to  prove  that  granulation 
or  immediate  secondary  union  have  given  excellent  results. 

The  line  of  suture  is  to  be  dusted  with  iodoform  and  covered  with 
iodoform  gauze.  The  catheter  should  not  be  left  in  the  bladder,  as 
there  is  danger  of  its  causing  cystitis,  but,  if  the  patient  be  unable  to 
pass  her  urine  spontaneously,  an  aseptic  catheter  may  be  introduced 
every  six  hours.  Shall  the  bowels  be  rendered  constipated  or  loose  ? 
I  consider  it  best  to  prevent  defecation  until  the  fourth  day,  and  then 
to  give  an  enema.  The  patient  will  of  course  have  been  thoroughly 
purged,  and  the  rectum  washed,  before  the  operation.  Two  tablets  of 
.opium  daily,  one-third  of  a  grain  each,  will  be  quite  sufficient  to  pre- 
vent premature  evacuations  if  the  diet  be  light.  Should  the  patient 
still  feel  a  desire  to  defecate,  a  suppository  containing  1.4  grains  of 
the  extract  of  opium  may  be  used.  On  the  tenth  day  it  is  my  custom 
to  administer  an  ounce  of  castor  oil,  and  two  hours  later  an  enema  of 
four  teaspoonfuls  of  the  oil  of .  sweet  almonds  with  two  of  glycerin. 
After  this,  the  bowels  are  closely  watched  to  insure  regular  daily 
movements.     The  patient  is  to  keep  her  bed  for  a  month. 

Immediate  and  Remote  Results  of  t?te  Operation  of  Colpo-peri- 
neorrliapliy. — Those  gynaecologists  who  have  the  most  frequently 


PROLAPSE  OP  THE  GENITAL  ORGANS.  511 

performed  this  operation  are  unanimous  in  testifying  to  its  safety  and 
efficacy.  In  what  follows,  I  refer  more  especially  to  the  operation  of 
Hegar,  which  seems  to  me  the  most  practical,  and  to  that  of  Martin, 
which  is  of  the  greatest  use  where  the  vaginal  walls  are  exceptionally 
loose  and  habby;  in  this  latter  case  Hegar's  method,  if  used,  would 
have  to  be  preceded  by  an  elliptical  posterior  elytrorrhaphy,  as  he 
himself  admits.44 

The  accidents  to  be  feared  are:  Puncture  of  the  peritoneum,  which, 
if  the  operation  be  conducted  under  strict  antisepsis,  is  not  of  grave 
import;  wounding  the  rectum,  which' a  well-applied  suture  will  rem- 
edy ;  suppuration  and  destruction  of  the  suture,  which  may  be  avoided 
by  a  careful  preparation  of  the  catgut  and  the  minutest  precautions 
against  possible  infection.  Out  of  400  cases  operated  upon  in  his 
cliiiic,  Hegar  has  seen  but  2  deaths  from  septicaemia,  and  in  both 
cases  it  was  ascertained  that  the  infection  was  carried  from  cases  pre- 
viously operated  upon.  Dorff,45  who  is  Hegar's  assistant,  has  pub- 
lished an  interesting  series  of  statistics  upon  the  remote  results  of  136 
operations.  He  was  able  to  secure  positive  information  in  only  63  of 
the  cases;  of  this  number  53  reported  a  j)erfect  cure  (some  after  a 
lapse  of  ten  years),  9  reported  successful  parturition  without  subse- 
quent relapse;  in  10  patients  the  operation  had  failed,  either  in  the 
first  place  or  at  a  later  date,  in  2  of  them  after  labor.  The  immediate 
results  are  even  more  gratifying:  For  a  period  of  three  years  and  a  half, 
during  which  he  has  performed  this  operation  150  times,  Hegar  has 
not  had  one  failure.46  Ernest  Colin,4,7  in  a  scholarly  treatise  upon  the 
cases  in  Schroder's  clinical  and  private  practice,  reports  that  of  74 
women  whom  it  was  possible  to  keep  under  observation  after  the  opera- 
tion, 46  were  permanently  cured;  tha  tis,  67.5$.  Hospital  cases  alone 
give  56$,  and  clinical  cases  report  86.7$.  (These  are  all  cases  where 
Hegar's  method  was  employed  with  a  continuous  suture  in  layers,  using 
catgut  prepared  in  oil  of  juniper.)  Three  of  the  patients  went  success- 
fully through  labor. 

II  Shortening  the  Mound  Ligaments  for  Prolapse  of  the 
Uterus. — This  is  the  Alquie- Alexander- Adams  operation.  For  a  de- 
tailed description  the  reader  is  referred  to  the  chapter  on  Retroflexion 
(p.  452).  The  success  of  this  operation  alone,  when  performed  for  the 
relief  of  prolapsus,  is  not  in  the  main  brilliant,  although  some  good 
results  have  been  reported.48  But  it  is  of  undoubted  usefulness  when 
combined  with  plastic  operations  upon  the  perineum  and  vagina,  es- 
pecially in  thin  women  whose  abdominal  walls  are  not  too  lax.     It 


512  CLINICAL    AND    OPEKATIVE    GYNECOLOGY. 

seems  to  me  that  its  chief  action  is  the  correction  of  the  retroversion 
which  accompanies  and  is  a  prominent  feature  of  prolapsus. 

III.  Suture  of  the  Uterus  to  the  Abdominal  Wall — Ventro- 
fixation.—The  history  and  description  of  this  operation  are  given  in 
the  preceding  chapter  (page  460). 

If  an  abdominal  tumor,  fibroid  or  cystic,  complicate  the  case,  it  will 
be  an  excellent  procedure  after  laparatomy  to  fix  the  pedicle  into  the 
wound.  One  of  my  patients  was  cured  by  this  procedure  after  an 
ovariotomy.  Schroder  quotes  similar  cases;  and  analogous  facts  are 
reported  by  Olshausen,  Brennecke,  TTeist,  etc.  (See  history  of  Ventro- 
fixation, page  460). 

It  is  important  to  remember  that  ventro-fixation  is  not  adapted  to 
the  cure  of  prolapse  of  the  genital  organs  in  toto,  but  only  to  pro- 
lapse  of  the  uterus  itself.  Unless  this  have  fallen,  it  would  not  be 
justifiable  to  fix  it  to  the  abdominal  walls  simply  because  of  the  ex- 
istence of  a  cystocele  and  rectocele.  Neither  would  ventro-fixation 
alone  suffice  to  cure  a  prolapse  of  the  uterus  if  it  were  accompanied 
by  prolapse  and  distention  of  the  vaginal  walls  and  a  supra-vaginal 
hypertrophy  of  the  cervix.  From  a  theoretical  as  well  as  a  practical 
point  of  view,  this  operation  is  adequate  only  in  those  relatively  rare 
cases  where  an  unenlarged  uterus  alone  is  prolapsed.  In  all  other 
cases,  supplementary  operations  upon  the  cervix,  vagina,  or  perineum 
will  be  found  necessary ;  the  conoidal  amrmtation  of  Huguier,  or  bi- 
conical  amputation  of  Simon;  anterior  and  posterior  elytrorrhaphy, 
the  various  forms  of  colpo-perineorrhaphy,  Le  Fort's  closure  of  the 
vagina,  etc. 

It  Avould  seem  then  that  ventro-fixation  possesses  no  advantages 
over  Alexander's  operation,  which  is  also  rarely  adequate  in  compli- 
cated cases,  but  a  very  valuable  auxiliary.  It  is  really  between  these 
two  operations  that  a  comparison  should  be  instituted,  from  the  point 
of  view  of  both  danger  and  efficacy.  It  is  unnecessary  to  dwell  upon 
the  first  point,  the  relative  safety  of  Alexander's  operation  being  well 
known.  This  fact  does  not  by  any  means  settle  the  question  of  a 
choice,  but  it  should  influence  the  conscientious  surgeon  not  to  resort 
to  the  more  serious  operation  before  having  tried  the  less  serious  one. 
As  to  the  question  of  efficacy,  experience  will  not  as  yet  justify  a 
judgment  in  favor  of  gastro-fixation,  as  the  operation  has  too  recently 
come  into  prominence  and  has  been  too  seldom  performed. 

The  first  patient  operated  upon  by  Olshausen 49  had  a  speedy  re- 
turn of  the  displacement,  but  it  would  seem  that  in  her  case  the 


PROLAPSE   OF   THE   GENITAL   ORGANS.  513 

sutures  were  insufficient  (two  stitches  of  silkworm  gut  at  the  inser- 
tion of  each  round  ligament).  The  second  operation  by  the  same  sur- 
geon, where  fixation  was  superadded  to  an  ovariotomy,  was  successful, 
the  patient  reporting  a  complete  cure  in  1886,  a  year  and  a  half  after 
the  operation.  Phillips 50  reports  a  case  where  the  cure  had  lasted 
for  six  months,  the  last  observation  being  taken  at  the  moment  of 
publishing  the  report;  in  this  case  also  the  pedicle  of  a  removed 
ovary  was  fastened  to  the  abdominal  wall.  Dumoret 51  reports  eight 
successful  cases  out  of  eleven  such  operations.  Terrier's  three  cases 
and  those  of  Tuffier 52  are  of  too  recent  date  to  add  much  to  our 
knowledge  of  results.  Two  failures  and  one  death  are  facts  not  to  be 
overlooked,  and  scarcely  justify  the  enthusiasm  displayed  by  some 
surgeons  over  this  operation.  Foreign  operators  do  not  seem  to  favor 
ventro- fixation  for  prolapsus.  Kelly 53  disputes  its  value.  Muller  has 
performed  it  from  twelve  to  fifteen  times  without  good  result,  the  pro- 
lapse of  both  uterus  and  vagina  scon  recurring.  In  some  cases,  the 
adhesions  to  the  abdominal  walls  have  given  way;  in  others  they  have 
remained,  but  the  walls  have  been  dragged  down  out  of  place.  Hof- 
meier  has  seen  no  good  results  from  Schroder's  operations ;  Freund,  to 
explain  these  failures,  calls  attention  to  the  fact  that  even  after  a 
myomotomy  with  extra-peritoneal  fixation  of  the  pedicle,  the  latter 
often  becomes  detached  from  the  abdominal  wall.  Fehling,  out  of 
three  cases,  had  one  successful  result.54 

Moreover,  if  there  be  much  hypertrophy  of  the  cervix  and  vaginal 
prolapse,  though  the  uterus  be  firmly  fixed  in  place  or  even  removed, 
the  vaginal  prolapse  will  return.  This  has  happened  where  vaginal 
hysterectomy  had  been  performed.  Muller 55  (of  Berne)  has  met  with 
this  deplorable  result  after  the  serious  operation  of  abdominal  supra- 
vaginal hysterectomy,  with  fixation  of  the  pedicle  in  the  abdominal 
wound.  The  woman  was  thirty-eight  years  of  age,  had  had  one  child, 
and  suffered  from  complete  prolapsus  of  the  uterus.  Muller  had  per- 
formed Bischoff's  operation  of  colpo-perineorrhaphy  upon  her  in  De- 
cember, 1878,  but  without  good  results.  June  16th,  1879,  he  made  an 
incision  in  the  linea  alba  about  2.5  inches  in  length,  and  by  means  of 
a  sound  in  the  uterus  brought  this  organ  into  the  abdominal  opening, 
placed  a  clamp  upon  it  and  excised  the  upper  portion,  suturing  the 
lower  portion  to  the  lips  of  the  external  wound.  The  patient  left  her 
bed  on  the  16th  of  July,  cured.  In  November  of  the  same  year  her 
menses  had  returned  twice,  as  a  sanguineous  oozing  through  the  vulvar 
and  the  abdominal  cicatrix.     The  latter  was  much  depressed,  or  rather 


514  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

was  at  the  base  of  a  narrow  infundibulum — formed  by  the  abdominal 
walls.  The  uterine  prolapse  had  returned  in  full  force ;  the  cervix 
protruding  from  the  vulva  about  3.5  inches.  Its  lips  were  swollen 
and  admitted  the  first  phalanx  of  the  index  finger.  It  seems  to  me  that 
this  case  proves  conclusively  that  support  from  above  does  not  suffice 
to  keep  the  uterus,  or  even  a  stump  of  the  uterus,  in  place  when  a 
hypertrophied  cervix  and  prolapsed  vagina  are  continually  pulling 
upon  it  from  below.  Yentro-fixation,  like  Alexander's  ox^eration,  un- 
less the  case  be  one  of  simple  uterine  prolapse,  should  always  be  com- 
bined with  an  operation  upon  cervix,  vagina,  or  perineum  if  durable 
results  are  to  be  obtained. 

We  might  rank  with  ventro-fixation  a  new  procedure  described 
and  performed  by  H.  T.  Byf ord 56  for  the  cure  of  cystocele,  and  which 
he  proposes  to  use  as  a  complement  to  Alexander's  operation,  utilizing 
the  same  incision  and  carrying  it  more  deeply  into  the  cellular  tissue 
in  order  to  suture  the  vagina.  Byford  carries  the  incision  through 
the  inguinal  canal  to.  the  retro-pubic  cellular  tissue  (cavity  of  Retzius), 
which  he  separates  from  the  pubis,  being  careful  to  ascertain  the 
exact  situation  of  the  ureter  by  bimanual  examination.  He  next 
passes  a  needle  threaded  with  silkworm  gut  from  above  downwards 
through  the  vaginal  wall  into  the  left  lateral  cul-de-sac.  The  needle 
is  then  carried  from  below  upward  through  the  vagina  about  a  quarter 
of  an  inch  from  the  point  of  entrance  and  emerges  through  the  ingui- 
nal wound.  A  loop  of  silkworm  gut  thus  holds  a  small  portion  of 
the  anterior  vaginal  wall ;  another  suture  is  firmly  embedded  in  the 
cellular  tissue,  the  threads  are  drawn  taut  and  tied  over  the  inguinal 
canal  and  the  incision  upon  the  posterior  wall  of  this  canal  is  closed. 
The  same  operation  is  repeated  upon  the  other  side,  and  the  vaginal 
wall  is  drawn  up  to  the  middle  of  the  pubic  bone,  uijlifting  and  sup- 
porting the  bladder.  Byford  claims  that  it  is  of  the  utmost  import- 
ance to  include  in  the  suture  some  of  the  vaginal  mucous  membrane 
in  which  the  thread  sinks  and  is  gradually  buried,  thus  imparting  ad- 
ditional strength.  When  operating  upon  both  sides,  especial  care 
must  be  taken  not  to  bring  the  sutures  too  near  the  urethra,  for  fear 
of  diminishing  its  calibre.  The  ureter  also  is  to  be  avoided.  Byford 
has  twice  performed  this  operation.  The  first  time  it  resulted  in  a 
failure,  which  he  attributes  to  a  lack  of  experience  in  the  details. 
The  second  operation  was  a  success,  although  he  inserted  one  suture 
only,  on  the  left  side.  This  second  case,  however,  proves  little  or 
nothing.     The  patient  had  already  had  a  vaginal  hysterectomy  per- 


PROLAPSE  OF  THE  GENITAL  ORGANS.  515 

formed  on  her;  and  at  the  same  time  that  he  did  the  ventro-fixation, 
Byford  also  did  a  double  elytrorrhaphy,  besides  Martin's  colpo-per- 
ineorrhaphy.  It  is  very  probable  that  this  last  operation  alone  would 
have  sufficed;  at  all  events,  it  is  difficult  to  decide  how  much  of  the 
credit  belongs  to  the  first  operation.  Byford  calls  his  process  colpo- 
cystorrhaphy,  which  seems  to  me-  a  misnomer,  since,  although  the 
bladder  is  uplifted,  it  is  the  abdominal  wall,  and  not  that  organ,  which 
is  sutured  to  the  vagina.  Either  laparo-  or  ventro-fixation  is  a  better 
term. 

IV.  Vaginal  Hysterectomy. — Except  in  case  of  fibromata,  1  con- 
sider abdominal  hysterectomy  unjustifiable.  As  to  vaginal  hyster- 
ectomy, though  less  severe  than  this,  it  is  more  serious  than  plastic 
operations,  and  should  only  be  resorted  to  as  an  extreme  measure. 
The  vaginal  prolapse  may  persist  even  after  it  has  been  done,  and  in 
spite  of  the  removal  of  a  large  portion  of  the  vaginal  mucous  mem- 
brane, so  that  a  colpo-perineorrhaphy  may  still  be  necessary. 

Leopold  "  has  performed  this  operation,  but  does  not  recommend 
it.  Miiller  performed  it  three  times,  and  in  two  of  the  cases  had  to 
supplement  it  with  a  corporrhaphy.  Baumgarten  has  witnessed  the 
occurrence  of  vaginal  hernia  as  a  sequel.  On  the  other  hand,  Kehrer 58 
has  used  it  successfully  in  the  cure  of  a  uterus  prolapsed  for  the  sec- 
ond time,  and  Robert  Asch 59  reports  no  less  than  eight  cases  of  hyster- 
ectomy for  prolapsus  in  Fritsch's  clinic.  This  surgeon  combines  an 
extensive  resection  of  the  vagina  with  this  operation. 

T/ie  therapeutic  indications  of  the  various  types  of  prolapse  of 
the  genital  organs  may  be  thus  grouped:  We  may  employ  pessaries 
or  palliatives  (page  494)  after  reducing  the  displacement  by  rest,  baths, 
and  tampons,  and  if  necessary  amputation  of  the  hypertrophied  cer- 
vix. Massage 60  has  been  much  extolled  of  late  as  a  remedy  in  most 
of  the  uterine  affections,  especially  prolapsus.  I  think  it  destined  to 
render  real  aid,  when  combined  with  baths  and  rest,  in  diminishing 
the  size  of  the  prolapsed  parts  and*  facilitating  their  replacement. 
Brandt  recommends  massage  with  two  operators ;  one  of  them  lifts  the 
uterus  by  means  of  two  fingers  introduced  into  the  vagina ;  the  other 
places  both  hands  between  the  uterus  and  the  symphysis,  and  slowly 
presses  the  ends  of  the  fingers  as  deeply  as  possible,  lifts  them  and 
presses  them  down  again  about  a  dozen  times.  A  daily  application 
for  about  eight  days  will  be  sufficient.  It  would  be  useless  to  expect 
a  permanent  cure  from  this  treatment.  It  will  give  only  a  temporary 
relief,  and  cannot  replace  a  plastic  operation. 


516  CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 

In  tlie  consideration  of  curative  treatment  we  must  divide  the 
cases  into  several  classes. 

1.  Simple  Prolap>se  of  the  Vagina  without  Hypertrophy  of  the 
Cervix  or  Marked  Sinking  of  the  Uterus. — Anterior  elytrorrha- 
pliy  and  colpo-perineorrhaphy  (Hegar's  method)  if  the  vagina  be 
much  enlarged;  when  the  cystocele  is  small,  anterior  elytrorrhaphy 
followed  by  colpo-perineoplasty  by  flap-splitting  (Doleris'  method) 
to  increase  the  perineal  resistance. 

<2.  Vaginal  and  Uterine  Prolapse  loitli  Hypertrophic  Elonga- 
tion of  the  Cervix. — Biconical  amputation  of  the  cervix,  anterior 
elytrorrhaphy,  and  colpo-perineorrhaphy.  Hegar's  method  is  the  one 
to  be  ordinarily  employed,  but  Martin's  method  is  to  be  used  instead 
if  the  vagina  be  large  and  flabby,  as  more  of  the  surface  can  be  re- 
moved. 

If  the  body  of  the  uterus  be  much  prolapsed,  it  will  be  better  to 
shorten  the  round  ligaments  at  once,  after  amputating  the  cervix,  be- 
fore attempting  a  plastic  operation  upon  the  vagina.  This  combina- 
tion of  several  processes  for  the  cure  of  prolapse  of  the  genital  organs, 
and  in  especial  the  union  of  Alexander's  operation  to  colpo-perineor- 
rhaphy, was  first  suggested  by  Alexander  himself.  Munde61  and 
Doleris 62  warmly  praise  this  mixed  method.  It  seems  to  me  that 
shortening  the  round  ligaments  is  of  especial  value  in  correcting  the 
retroversion  which  frequently  accompanies  a  prolapsus  and  is  so  pow- 
erful a  cause  of  relapse.  It  may  sometimes  be  necessary  to  do  as 
many  as  five  operations  upon  the  same  patient ;  but  they  are  all  simple 
and  rapid  of  performance,  as  all  may  be  accomplished  within  an  hour, 
thanks  to  the  time  gained  by  the  use  of  the  continuous  suture  in 
layers.  Should  any  of  these  methods  fail,  ventro-fixation  may  be  com- 
bined with  the  vaginal  operations. 

When  the  prolapse  of  uterus  and  vagina  is  complete,  and  the  fallen 
organs  hypertrophied  and  replaced  and  maintained  in  position  with 
great  difficulty,  when  they  have  in  fact  apparently  lost  their  connec- 
tion with  the  pelvis,  it  will  be  quite  justifiable  to  perforin  a  vaginal 
hysterectomy,  with  extended  excision  of  the  vagina,  followed  by 
colpo-perineorrhaphy  to  diminish  the  vulvar  opening. 

3.  Prolapse  of  Uterus  and  Vagina  without  Hypertrophy  of  tlie 
Cervix. — Shortening  the  round  ligaments,  then  colpo-perineorrhaphy 
(Hegar  or  Martin's  method,  according  to  the  condition  of  the  vagina) 
or  Le  Fort's  closure  of  the  vagina.  As  every  case  of  prolapsus  is 
accompanied  by  endometritis,  one  will  always  begin  by  curetting. 


PBOLAPSE   OF   THE   GENITAL    ORGANS.  517 


BIBLIOGRAPHY  AND   NOTES. 

1.  Trelat :  Lecons  sur  les  Prolapsus  des  Organes  Genitaux  de  la  Femme.  Ann. 
de  Gyn.,  May,  188S. 

2.  Hart :  The  Structural  Anatomy  of  the  Female  Pelvic  Floor,  Edinburgh, 
1880. 

3.  Barnes:  Traite"  Pratique  des  Maladies  des  Femmes,  French  ed.,  1876,  p.  540. 
Mund6:  Forcible  and  Complete  Prolapse  of  the  Uterus  in  a  Virgin.  Amer.  Jour. 
of  Obstet.,  xxi.,  p.  70. 

4.  Dutauzin :  Etiologie  et  Symptomes  de  la  Chute  de  la  Matrice.  Paris  Thesis, 
1887. 

5.  Hart  and  Barbour:  Manuel  de  Gyn^cologie,  French  ed.,  1886,  p.  610. 

6.  B.  E.  Hadra:  Amer.  Jour,  of  Obstet.,  April,  1884,  p.  365.  U.  Tr61at:  Prolap- 
sus des  Organes  G6nitaux.     Ann.  de  Gyn.,  Sept.,  1888,  p.  174. 

7.  Doran  :   Transact,  of  the  Obstet.  Society  of  London,  1884,  p.  88. 

8.  U.  Trelat:  Loc.  cit.  (1),  p.  328. 

9.  Breisky:  Krankheiten  der  Vagina,  1886,  p.  69.  Etheridge:  Journal  of  the 
Amer.  Med.  Asso.,  February  5th,  1887.     Abstract  in  Centr.  f.  Gyn.,  1887,  No.  33. 

10.  A.  Martin:  Path,  und  Ther.  der  Frauenk.,  1887,  p.  121. 

11.  Hegar  and  Kaltenbach:  Traite"  des  Mai.  des  Fern.,  French  ed.,  p.  559. 

12.  Huguier:  Memoire  sur  l'Allongement  Hypertrophique  du  Col  de  l'Uterus, 
Paris,  1860.     M6moires  de  FAcad.  de  Me'decine,  1859,  vol.  xxiii.,  p.  279. 

13.  Courty:  Traite"  Pratique  des  Mai.  de  l'Uterus,  1881,  p.  589. 

14.  Gallard:  Lecons  Cliniques  sur  les  Mai.  des  Femmes,  1879,  p.  783. 

15.  Olivier,  in  Emmet:  Traite"  des  Mai.  des  Fern.,  French  ed.,  p.  496;  and  Note 
sur  un  Cas  d'Allongement  Hypertrophique.     Ann.  de  Gyn.,  Sept.,  1881. 

16.  Bastien  and  Legendre:  Bull.  Soc.  de  Chir.,  April,  1859. 

17.  Fer6:  Note  sur  les  Lesions  des  Organes  Urinaires  Cons6"cutives  a  la  Chute 
1  de  l'Utenis.     Progres  Medical,  1884,  p.  22. 

18.  Varnier:  Des  Cystoceles  Vaginales  Compliquees  de  Calculs,  avec  ou  sans 
Chute  de  l'Uterus,  Paris,  1886. 

19.  P.  de  Lostalot-Bachoue":  Des  Troubles  Visceraux  Consecutifs  a  l'Affaiblisse- 
ment  du  Plancher  Pelvien  chez  la  Femme.     Paris  Thesis,  1889. 

20.  Gosselin,  Clinique  Chirurgic,  vol.  ii.,  p.  534,  Paris,  1873,  was  so  much  im- 
pressed with  the  part  taken  by  the  protrusion  of  the  vaginal  mucous  membrane 
beyond  the  vulva,  in  the  causation  of  symptoms,  that  he  made  this  feature  the 
basis  of  his  classification,  and  distinguished  three  varieties  of  prolapsus  :  1.  Incom- 
plete descent  without  accompanying  prolapse  of  the  recto-  and  vesico-vaginal 
walls.  2.  Incomplete  descent,  but  with  prolapse  of  one  or  the  other  vaginal  wall. 
3.  Complete  descent  (procidentia)  with  the  cervix  protruding  beyond  the  vulva. 

21.  Fritsch:  Die  Krankh.  der  Frauen,  1886,  p.  276. 

22.  Duplay:  Contribution  a  l'Etude  des  Maladies  de  l'Urethre  chez  la  Femme. 
Archives  G6n6r.  de  M<5d.,  July,  1880.  Piedpremier:  De  l'Ur^throcele.  Paris 
Thesis,  1887.  D.  Temoin:  Contribution  a  l'Etude  des  Prolapsus  G6nitaux.  Paris 
Thesis,  1889.     Th.  A.  Emmet:  New  York  Med.  Journal,  October  27th,  1888. 

23.  Breisky:  Prager  med.  Wochenschr.,  1884,  No.  33. 

24.  Auvard,  under  the  head  of  Pessaries  in  the  Diet.  Encyclop.  des  Sci.  Me"d., 
suggests  the  name  of  "  Vagino-abdominal "  for  these  pessaries. 

25.  Fricke:  Annalen  der  Chirurg.  Abtheilung  des  Krankenhauses  in  Ham- 
burg, vol.  ii.,  1883,  p.  142. 

26.  Malgaigne:  Manuel  de  MeU  Oper.,  1873,  p.  738. 

27.  Dommes:  Hanover'sche  Annalen  fur  die  ges.  Heilk.,  vol.  v.,  p.  20. 


518  CLINICAL   AND    OPERATIVE   GYNECOLOGY. 

28.  Phillips:  London  Med.  Gazette,  vol.  xxi  v.,  p.  494  (nitric  acid).  Jobert  de 
Lamballe:  Gaz.  M<5d.  de  Paris,  1840,  No.  5  (nitrate  of  silver).  Desgranges  (quoted 
by  Malgaigne):  Chloride  of  zinc. 

29.  Langier,  Velpeau,  Kennedy,  Dieffenbach,  quoted  by  Schroder.  John 
Byrns  :  Trans,  of  the  Amer.  Gyn.  Soc,  1886,  recommends  as  an  after-treatment  of 
cervical  amputation,  the  application  of  the  gal vano-  cautery  so  as  to  form  a  cicatri- 
cial tissue  about  the  stump.     He  also  advises  linear  cauterization  of  the  vagina. 

30.  Gillette:  The  Radical  Cure  of  Rectoc.  and  Cystoc.  by  Ligature.  Obst.  Soc. 
of  New  York.     Amer.  Jour,  of  Obstet.,  xxi.,  p.  73.         J 

31.  Franck:  Arch.  f.  Gyn.,  Bd.  xxxi.,  p.  453. 

32.  Marshall  Hall:  Dublin  Journal  of  Med.  and  Chem.  Science,  January,  1825. 
Gaz.  MeU  de  Paris,  January  21st,  1832. 

33.  Simon:  Prager  Vierteljahrschr.,  1867,  Band  iii.,  p.  112.  Engelhardt:  Die 
Retention  des  Gebarmutter-Vorfalls,  Heidelberg,  1871. 

34.  Sims:  Uterine  Surgery,  London,  1865. 

35.  Schauta:  Centr.  f.  Gyn.,  1889,  p.  747. 

36.  Cohn,  Zeitschr.  f.  Geb.  und  Gynak.,  Bd.  xiv.,  Heft  2,  1888,  has  published 
some  important  statistics  in  regard  to  the  immediate  and  after  effects  of  plastic 
operations  for  prolapsus.  He  has  found  that  the  best  results  follow  the  use  of  the 
buried  suture  in  layers. 

37.  Freund:  Naturforscher-Versammlung,  Wiesbaden,  1873. 
38.'Metzinger:  Zur  Kolpoperineoplastik  nach  Bischoff.     Wiener  med.  Blatter, 

3d  year,  1880,  Nos.  27  et  seq. 

39.  Winckel:  Lehrbuch  der  Frauenk.,  1886,  p.  299. 

40.  Doleris:  Communication  Faite  a  la  Soc.  Obst.  de  Paris,  April  11th,  1889. 
Repertoire  Universel  d'Obst.  et  de  Gyn.,  1889,  p.  344. 

41.  MundeV  Minor  Surgical  Gynaecology,  New  York,  1885,  p.  522. 

42.  Leon  le  Fort:  Nouveau  Proc^de-  pour  la  Guenson  du  Prolapsus  Ut6rin. 
Bull,  de  Th<§r.,  April  30th,  1877.  Manuel  de  M<5d.  Op6r.  de  Malgaigne,  9th  ed.,  1889, 
vol.  ii.,  p.  785,  and  private  communication. 

43.  Le  Fort's  operation  differs  essentially  from  that  of  Spiegelberg  (Berliner 
klin.  Wochenschrift,  1872,  Nos.  21  and  22),  who  sutures  the  lowest  portion  of  the 
anterior  vaginal  wall  to  the  upper  portion  of  the  same  wall.  Neugebauer  (Centr. 
f.  Gyn.,  Nos.  1  and  2,  1881),  however,  claims  priority  in  the  operation,  which  A. 
Martin  credits  him  with  having  introduced  into  practice  (Path,  und  Ther.  der 
Frauenk.,  p.  138).  Consult  upon  this  point  Skoloff  (Annales  de  Gyn.,  1884,  vol. 
xxi.,  p.  13).  Neugebauer  called  his  operation  Elytrorrhaphia  mediana  sive  Elytro- 
cleisis  partialis  mediana,  1867.  Another  French  surgeon  may  possibly  have  antici- 
pated Le  Fort's  process.  I  refer  to  Jobert  de  Lamballe  (quoted  by  Le  Fort-Mai - 
gaigne:  Manuel  de  M<Sd.  Oper.,  9th  ed.,  1889,  vol.  ii.,  p.  729).  His  method  consisted 
in  denuding  longitudinally  two  strips  of  the  anterior  vaginal  wall,  leaving  between 
them  an  undenuded  portion.  When  the  freshened  surfaces  were  in  apposition 
and  sutured,  the  vagina  was  permanently  narrowed.  This  was  due  to  a  lateral 
closure  instead  of  a  central  one  as  in  Le  Fort's  process.  Jobert  simply  added  some 
improvements  to  the  method  of  Gerardin  (of  Metz),  who,  as  early  as  1823,  freshened 
and  joined  together  a  portion  of  the  lower  part  of  the  vaginal  walls.  (Andr6:  Du 
Traitement  du  Prolapsus  Ut6rin  par  l'Operation  de  Le  Fort.  These  de  Paris,  1889.) 
Eustache  has  slightly  modified  Le  Fort's  process.  He  denudes  a  surface  of  about 
three  inches  in  length,  from  the  cervix  to  the  vulva,  and  recommends  the  use  of 
catgut.  He  has  had  two  failures  with  the  unmodified  Le  Fort  operation,  and  five 
successful  results  with  the  modified  operation.  (Eustache:  Bull,  de  la  Soc.  de  Chir., 
November,  1881.)  Ch.  E.  Taft  (Le  Fort's  Operation  for  Complete  Procidentia  of  the 
Uterus,  with  Report  of  a  Case.     Amer.  Jour,  of  Med.  Sciences,  Aug.,  1889,  p.  128) 


PROLAPSE  OF  THE  GENITAL  ORGANS.  dl9 

reports  a  successful  case  in  America.  The  first  one  to  perform  Le  Fort's  operation 
in  that  country  was  Fanny  Berlin,  who  reports  three  cases  (Amer.  Journal  of 
Obstetrics,  1881,  p.  866). 

44.  Hegar  and  Kaltenbach:  Die  Operat.  Gyn.,  p.  577. 

45.  Dorff:  Wien.  Med.  Blat.,  Nos.  45  to  52,  1879,  and  1,  4,  and  5,  1880. 

46.  Hegar  and  Kaltenbach  :  Die  Operat.  Gyn.,  p.  773. 

47.  E.  Conn:  Ueber  die  primaren  und  deflnniven  Resultate  der  Prolapsopera- 
tion.     Zeitschrift  f.  Geburtsh.  und  Gyn.,  Bd.  xiv.,  Heft  2,  1888. 

48.  Polk  (Amer.  Jour,  of  Obstetrics,  June,  1886)  instances  15  successful  cases. 
As  there  Avas  no  plastic  operation  upon  the  vagina  the  result  must  have  been  en- 
tirely due  to  the  shortening  of  the  round  ligaments. 

49.  Olshausen  (Centr.  f.  Gyn.,  1886,  pp.  667  and  698)  was  the  first  to  perform 
ventro-fixation  for  the  cure  of  prolapsus;  he  was  the  inventor  of  the  process. 
Leopold  and  Czerny  have  slightly  modified  it  for  retroversion.  Terrier  was  the 
first  in  France  to  apply  Olshausen's  method  with  Czerny's  modifications  to  uterine 
prolapse. 

50.  Phillips:  On  Ventral  Fixation  of  the  Uterus  for  Intractable  Pralapse. 
Lancet,  October  20th,  1888. 

51.  Dumoret:  Laparo-hysteropexie.     These  de  Paris,  1889,  p.  99. 

52.  Dumoret:  Loc.  cit. 

53.  H.  Kelly:  Amer.  Jour,  of  Obst.,  January,  1887,  p.  33. 

54.  Miiller,  Hofmeier,  Freund,  Fehling:  Meeting  of  Germ.  Natur.,  Heidelberg 
1889.     Centr.  f.  Gyn.,  1889,  p.  747. 

55.  J.  Rendu  (Notes  sur  quelques  Voyages  a  l'Etranger  au  Point  de  Vue  de 
l'Obst£trique  et  de  la  Gyn^cologie.  Lyon  Medical,  1880)  has  published  the  results 
of  one  of  Miiller's  operations  with  the  following  title:  Enorme  Prolapsus  Uterin; 
Laparotomie  suivie  de  l1  Amputation  de  la  Partie  Superieure  de  l'Ut6rus  et  de  la 
Fixation  du  Moignon  dans  la  Plaie  abdominale;  R^cidive. 

56.  Henry  T.  Byford:  The  Cure  of  Cystocele  by  Inguinal  Suspension  of  the 
Bladder;  Colpo-cystorrhaphy.  Amer.  Jour,  of  Obstetrics,  vol.  xxiii.,  p.  152,  Feb- 
ruary, 1890. 

57.  Munchmeyer:  Congress  of  German  Gynakologists,  Freiburg,  1889.  Centr. 
f.  Gyn.,  1889,  No.  31. 

58.  Miiller,  Baumgartner,  Kehrer:  Centr.  f.  Gyn.,  p.  747,  1889. 

59.  Robert  Asch:  Extirpation  des  Uterus  mit  Resection  der  Scheide  wegen 
Vorfalls.     Arch.  f.  Gyn.,  Bd.  xxxv.,  Heft  2,  1889. 

60.  F.  Sielski:  Das  Wesentliche  der  Thure  Brandt'schen  Behandlungs-Methode 
des  Uterusprolapsus.  Centr.  f.  Gyn.,  1P89,  No.  4.  He  recommends  massage  and  a 
modification  of  it  which  consists  in  replacing  the  uterus  by  means  of  a  sound  with 
an  enlarged  tip.  E.  Strovnowski  (Centr.  f.  Gyn.,  1889,  No.  29)  reports  two  cases  of 
uterine  prolapse  cured  by  massage  administered  by  two  operators,  as  Brandt 
recommends.  K.  Pawlik  (Beitrage  zur  Behandlung  des  Gebarmuttervorfalles. 
Centr.  f.  Gyn.,  1889,  No.  13)  applied  massage  in  prolapsus  with  negative  results. 

61.  Munde:  Amer.  Jour.  Obst.,  xxi.,  p.  70. 

62.  Doieris:  Nouv.  Arch.  d'Obst,  et  de  Gyn.,  p.  350,  1886  and  1S90,  p.  118. 


CHAPTER  XX. 


INVERSION  OF   THE   UTERUS. 

Inversion  of  the  uterus  may  be  detinecl  as  the  turning  in  of  the 
organ  upon  itself,  so  that  the  fundus  which  is  pushed  down  like  the 
end  of  a  glove  finger  protrudes  either  into  the  uterine  cavity  or  the 
vagina. 

The  first  stage  of  that  process  usually  escapes  notice,  and  may 
indeed  be  only  temporary  in  its  duration.  To  attract  the  attention 
of  the  physician,  the  fundus  must  protrude  through  the  cervix  and 
form  a  tumor  which  touch  or  sight  can  appreciate.     The  various  de- 


Fig.  291.— Inversion  of  Uterus.    Schematic  representation  of  the  three  degrees,    a,  Fundus  inverted ; 
b,  in  uterine  cavity  ;  c,  in  vagina  ;  d,  upper  edge  of  the  depression  formed  by  the  inverted  fundus. 

grees  into  which  the  classic  authorities  divided  inversion  (Fig.  291 ) 
have  merely  a  theoretical  interest.  The  division  into  complete  and  in- 
complete has  not  much  more  value ;  complete  inversion,  where  any 
projection  of  the  cervix  is  entirely  obliterated,  is  so  rare  that  the 
existence  of  even  the  few  cases  quoted  is  a  matter  of  dispute. 

The  only  classification  of  any  clinical  importance  is  that  of  simple 
inversion  and  of  inversion  with  prolapsus. 

Pathology — Etiology. —For  the  production  of  inversion,  there 
must  be  a  loss  of  tone  of  some  portion  of  the  uterus  which  excites  the 
contraction  of  the  uterine  muscles  just  above  it.  These  conditions 
are  found  after  labor,  or  as  the  result  of  a  fibroma  growing  into  the 
cavity.  In  both  of  these  conditions  the  uterus  is  hypertrophied  and 
dilated ;  in  both,  a  zone  of  its  surface  is  inert  and  depressed.     After 


INVEESION   OF   THE    UTERUS. 


521 


labor,  this  zone  is  at  the  placental  site,  so  that  Rokitansky x  has  de- 
scribed the  affection  as  a  "paralysis  of  the  placental  zone."  In  the 
case  of  fibroma  it  is  at  the  site  of  the  implantation  of  the  tumor. 
Traction  exerted  from  below  upon  the  umbilical  cord,  or  an  impulse 
from  above  produced  by  exaggerated  action  of  the  abdominal  walls 
when  there  is  uterine  inertia,  may  in  this  case  depress  the  fundus. 
If  the  rest  of  the  organ  is  then  about  to  contract,  the  depressed  portion 
is  seized  upon,  as  it  were,  and,  by  an  automatic  motion  which  may  be 


Fig.  292. — Inversion  op  the  Uterus  Without  Prolapse. 


compared  to  deglutition,  carried  down  through  the  cervix.  A  slight 
inversion  will  give  rise  to  contractions  in  a  direction  opposite  to  their 
usual  one. 

Among  the  more  frequent  causes  we  may  mention :  Shortness  of  the 
umbilical  cord  with  excessive  dragging  upon  the  placenta ;  abnormal 
adhesion  of  the  placenta  or  its  insertion  upon  the  fundus ;  labor  in  an 
erect  position.  Partial  inversion  often  occurs  without  the  knowledge 
of  the  attending  physician,  and  the  fundus  which  is  cupped  like  the 
bottom  of  a  bottle,  to  use  Mauriceau's  expression,  continues  to  descend 


522 


CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 


in  the  first  few  days  following  parturition,  and  the  inversion  which 
occurred  in  the  first  moment  is  noticed  only  after  a  lapse  of  several 
days.  Sometimes  it  becomes  slowly  appreciable,  sometimes  very  sud- 
denly. Its  origin  at  the  puerperal  period  is  the  most  frequent.  Crosse,2 
out  of  400  cases  of  inversion,  found  that  350  were  due  to  labor  and  50 
to  polypus.  Fibrous  bodies,  fibro-sarcomata  in  the  fundus,  especially 
if  they  have  been  subjected  to  traction,  may  cause  an  inversion  even 
in  nulliparae.     The  existence  of  these  tumors  leads  to  a  condition  of 


Fig.  293. — Inversion  akd  Prolapse  op  the  Uterus  Caused  by  a  Fibroid  Tumor. 


hypertrophy  and  vascularity  bearing  a  close  resemblance  to  the 
gravid  uterus  (grossesse  fibreuse). 

Inversion  is  a  rare  affection.  According  to  Beigel's  statistics,  it 
occurs  only  once  in  190,000  cases  of  labor. 

Pathological  Anatomy. — A  marked  distinction  should  be  made 
between  recent  inversions  in  the  puerperal  state  and  chronic  inver- 
sions in  the  same  condition.  The  peculiar  condition  of  the  uterus  at 
the  moment  of  delivery  establishes  a  radical  difference  between  the 
two.  Under  the  first  head  there  is  one  variety  which  may  be  called 
acute  and  which  is  so  formidable  an  occurrence  that  it  may  cause 


INVERSION    OF   THE    UTEBTJS. 


523 


death  from  profuse  hemorrhage.     It  is  fortunately  so  rare  that  I  need 
not  dwell  upon  it,  but  leave  its  description  to  the  obstetrician. 

By  recent  inversion  I  mean  cases  where  the  inversion  constitutes 
the  chief  symptom  to  be  treated,  and  may  be  made  manifest  to  the 
surgeon  at  any  time  not  too  far  removed  from  delivery  (usually  a 
month  and  a  half)  when  the  involution  of  the  uterus  is  still  incom- 
plete. By  chronic  inversion  I  mean  cases  of  much  longer  standing. 
In  the  recent  cases  the  cup-shaped  depression  of  the  fundus  is  usually 
pronounced  and  contains  the  Fallopian  tubes,  the  ovaries,  and  some- 
times loops  of  intestine  (Fig.  294).  At  a  later  stage  this  cavity  dis- 
appears, leaving  only  a  slit.  The  uterine  tumor  is  large,  its  tissue 
spongy  and  vascular.     The  surface,  which  is .  soft  and  downy,  is  in 


Fig.  294. — Inversion  of  the  Uterus,  a,  Vagina;  6,  fundus;  c,  c,  upper  borders  of  the  inversion;  c,  d, 
portion  of  cervix  not  inverted;  /,  cul-de-sac  formed  by  the  inversion  of  the  fundus;  g,  g,  Fallopian  tubes 
dragged  downward  by  the  inversion;  k,  k,  round  ligaments;  h,  h,  ovaries;  i,  i,  broad  ligaments. 


contact  with  the  vaginal  mucous  membrane.  By  careful  observation 
we  find  two  small  lateral  openings  about  an  inch  apart,  into  which  we 
can  sometimes  pass  a  hog's  bristle;  these  are  the  openings'  of  the 
Fallopian  tubes.  The  upper  part  of  this  pyriform  tumor  is  set  into 
the  cervical  ring.  When  the  cervix  shares  in  the  process  of  inversion, 
it  does  so  in  an  irregular  manner — the  anterior  cul-de-sac  being  of  a 
greater  depth  than  the  posterior.  Upon  the  uterine  mucous  mem- 
brane can  be  seen,  both  macroscopically  and  microscopically,  the  lesions 
of  glandular  endometritis. 

Chronic  inversion  without  prolapsus  forms  a  tumor  which  in  aspect 
and  consistency  is  much  like  a  fibrous  polypus,  the  pedicle  being- 
represented  by  that  part  of  the  body  which  is  compressed  by  the 
cervix.  The  cervix  remains  in  its  normal  position,  though  in  some  rare 
cases  of  complete  prolapsus  the  cervical  ring   disappears  and  the 


524  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

uterine  and  vaginal  mucous  membranes  are  directly  continuous.  In  a 
chronic  inversion  the  mucosa  of  the  uterus  often  takes  on  the  external 
characteristics  of  the  vaginal  mucosa,  its  glands  disappearing  in 
great  measure  (Schroder). 

Chronic  inversion  with  prolapsus  is  rare;  it  may  be  accompanied 
by  ulceration  due  to  friction  and  irritation.  The  mucous  membrane 
becomes  skin -like  in  its  nature  by  the  formation  of  layers  of  pave- 
ment epithelium  upon  its  surface. 

Cases  have  been  reported  of  a  species  of  spontaneous  cure  in  which 
the  inverted  uterus  was  eliminated  by  sloughing. 

Symptoms. — I  shall  make  no  reference  to  the  acute  inversion  at 
the  time  of  delivery,  as  it  is  a  condition  which  cannot  escape  the  notice 
of  a  careful  physician.3  If  this  inversion  is  only  partial,  the  accom- 
panying hemorrhage  may  not  be  alarming  in  its  nature. 

Inversion  in  the  puerperal  state  may  occur  suddenly  and  be  ac- 
companied by  sharp  pain  with  grave  reflex  phenomena,  even  to 
syncope.  In  a  few  cases  pain  has  been  absent;4  hemorrhage  may  or 
may  not  be  present.  If  the  inversion  has  taken  place  slowly  and  by 
degrees,  as  is  usually  the  case  when  polypi  are  the  cause,  the  symp- 
toms may  in  no  wise  differ  from  those  of  simple  prolapsus :  metror- 
rhagia, however,  is  the  rule,  and  should  call  for  careful  attention. 
All  the  group  of  uterine  symptoms  have  been  noted:  pain,  leucorrhoea, 
reflex  symptoms  in  the  digestive  tract  and  nervous  system,  and  some- 
times phenomena  of  compression  of  the  rectum  and  bladder.  The 
tumor  formed  by  the  uterus  resembles  a  polpus,  but  bimanual  palpa- 
tion will  convince  us  that  the  uterus  is  not  behind  the  pubis  but  filling 
the  vagina.  The  signs  of  inversion  may  be  combined  with  those  of 
prolapsus,  but  this  is  rare.5 

Diagnosis. — There  are  two  mistakes  possible:  A  simple  inversion 
may  be  taken  for  a  tumor  (polypus),  or  an  inversion  complicated  by  a 
tumor  may  not  be  recognized.  Whenever  a  supposed  polypus  has  a 
large  pedicle,  we  must  be  on  our  guard  against  falling  into  these 
errors.  Certain  positive  signs  will  enable  us  to  avoid  them ;  the  ab- 
sence of  the  rounded  mass  of  the  uterus  behind  the  pubis,  demon- 
strated by  rectal  touch,  hypogastric  palpation,  and  a  catheter  in  the 
bladder;  a  circular,  pad-like  constriction  all  around  the  tumor  behind 
which  the  sound  cannot  be  inserted ;  the  recognition  of  the  openings 
of  the  Fallopian  tubes — all  these  are  the  signs  of  a  simple  inversion. 

Inversion  accompanying  a  polypus  is  more  difficult  of  recogni- 
tion, and  it  is  often  hard  to  determine  to  which  cause  the  symptoms 


INVERSION   OF   THE    UTERUS.  525 

are  due.  As  a  diagnostic  sign,  some  authorities  have  mentioned  the 
sensitiveness  of  the  uterine  mucous  membrane  in  contradistinction  to 
the  lack  of  sensitiveness  of  the  surface  of  a  fibroid  (Tillaux,  Gueniot, 
Gosselin).  The  value  of  this  sign  has  been  disputed,6  and  it  is  evi- 
dently not  pathognomonic. 

The  greater  flexibility  and  deeper  color  of  the  uterine  tissues  indi- 
cate very  little,  nor  does  the  consistence  of  the  tissue  as  shown  by 
thrusting  in  a  pin  reveal  much  more.  If  a  thorough  examination 
during  anaesthesia  does  not  decide  the  matter,  I  think  it  would  be  ad- 
visable to  tie  an  elastic  ligature  about  the  pedicle,  and  incise  the  sur- 
face of  the  tumor  in  one  place  after  another  to  a  sufficient  depth  to 
ascertain  whether  or  not  a  fibroid  be  present ;  if  a  capsule  be  found, 
the  tumor  may  be  enucleated  with  blunt  instruments,  after  which 
iodoform  tampons  may  be  inserted  and  the  inversion  reduced.  If  the 
incision  give  a  negative  result,  it  can  be  carefully  closed,  by  a  suture 
in  layers,  before  removing  the  haemostatic  ligature.  Such  an  explora- 
tion would  not  be  dangerous,  and  would  prevent  the  disagreeable  sur- 
prises which  some  surgeons  have  experienced  who  have  undertaken 
complete  extirpation  of  the  tumor  without  preliminary  precautions. 

Simple  prolapsus  of  the  uterus  cannot  long  interfere  with  a  diag- 
nosis. The  disappearance  of  the  vaginal  culs-de-sac,  the  presence  of 
the  os  uteri  through  which  the  sound  can  be  inserted  usually  to 
more  than  the  normal  depth,  will  permit  of  its  ready  recognition. 
Obliteration  of  the  os  and  the  coexistence  of  a  fibroid  tumor  might 
cause  difficulty  and  is  a  complication  for  which  one  should  be  pre- 
pared. 

Prognosis. — Once  acquired,  inversion  tends  to  increase.  More- 
over, the  patients  are  exhausted  by  hemorrhages,  leucorrhoea,  and  pain. 
It  is  useless  to  build  any  hopes  upon  the  few  cases  reported  of  a 
spontaneous  reduction7  of  the  displacement,  or  of  those  still  more  ex- 
ceptional cases  of  gangrene,  which,  while  effecting  a  cure,  is  by  no 
means  free  from  danger.  We  must,  however,  not  ignore  the  fact  that 
a  remarkable  tolerance  may  be  acquired  for  even  the  most  serious 
lesions. 

Treatment. — Reduction  is  most  easily  accomplished  immediately 
after  the  occurrence  of  the  inversion.  As  soon  as  possible  after  de- 
livery, having  assured  himself  that  no  fragments  of  the  placenta  are 
left  behind,  the  physician  will  introduce  one  hand  into  the  uterine 
cavity  and  push  the  depressed  fundus  into  j)lace,  which  the  other 
hand,  strongly  pressing  upon  the  abdomen,  Avill  seize  and  hold.s 


526  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

Iii  a  chronic  case,  the  reduction  is  accomplished  with  far  more 
difficulty,  and  yet  some  apparently  permanent  inversions  have  been 
cured.  Audige9  reports  a  successful  reduction  in  a  case  of  thirty 
years'  standing. 

The  methods  of  reduction  employed  may  be  divided  into  forcible 
and  gradual  reposition. 

Forcible  Reposition. — I  shall  merely  enumerate  these  methods, 
without  dwelling  upon  them,  for  I  believe  that  they  will  fall  into  dis- 
use;10  the  great  majority  of  inversions  can  be  reduced  by  the  gradual 
method,  and  the  exceptional  cases  which  will  not  yield  to  this  treat- 
ment are  better  treated  by  extirpation  of  the  organ  than  by  forced 
taxis. 

For  manual  reduction  the  patient  is  anaesthetized;  three  fingers 
are  introduced  into  the  vagina  and  seize  the  tumor;  the  other  hand 
grasps  the  uterus  through  the  abdominal  walls  and  serves  to  direct 
the  pressure.  Two  methods  have  been  suggested.  One  the  reduction 
in  mass,  by  grasping  the  whole  of  the  inverted  uterus;  the  other  a 
gradual  reduction,  replacing  first  one  horn  of  the  uterus  and  then  the 
other  (jNoggerath).  Emmet11  recommends  -dilatation  of  the  cervix 
with  the  fingers  of  one  hand,  while  the  palm  of  the  other  presses  upon 
the  fundus.  Courty12  draws  down  the  uterus  with  Museux's  for- 
ceps, fixes  the  cervix  in  place  by  two  fingers  hooked  into  the  rectum, 
and  with  the  thumb  and  index  of  the  other  hand  presses  upon  the 
pedicle  so  as  to  gradually  diminish  the  utero-cervical  groove.  Courty 
sometimes  lessens  the  constriction  by  two  or  three  longitudinal  in- 
cisions which  start  from  the  os  and  extend  upon  the  cervix,  dividing 
its  circular  fibres.  Barnes  also  uses  this  method.  Emmet  advises, 
when  the  fundus  has  been  replaced  within  the  cervix  but  not  com- 
pletely reduced,  the  suture  of  the  os  for  a  few  days  to  prevent  a  pos- 
sible return  of  the  inversion. 

Instrumental  taxis  by  means  of  Viardel's  drumstick  repositor  or 
White's  instrument,  which  has  a  sort  of  cup  to  hold  the  tumor  and  an 
elastic  spring  at  the  other  end  which  is  held  against  the  chest  of  the 
orjerator,  possesses  for  us  only  an  historic  interest. 

Gaillard  Thomas,13  on  account  of  the  difficulties  encountered  in 
operating  through  the  vagina,  because  of  the  cervical  constriction, 
performed  a  laparatomy,  dilated  the  cervical  ring  with  an  instrument 
shaped  like  a  glove-stretcher,  and  with  great  difficulty  pushed  the 
uterus  upward  through  the  vagina.  The  vagina  was  perforated,  and 
the  patient  had  a  severe  hemorrhage  but  recovered;  a  second  one  died. 


INVERSION   OF   THE   UTERUS.  527 

In  view  of  these  risks,  I  cannot  agree  with  a  recent  writer 14  who  con- 
siders this  operation  as  one  to  be  highly  recommended,  for  even  in 
patients  young  enough  to  have  children  hysterectomy  seems  to  me 
safer. 

Gradual  Reduction. — Rest  in  bed,  hot  vaginal  injections,  and 
massage  should  all  be  used  to  diminish  congestion  and  reduce  the 
size  of  the  uterus.  "With  these  aids  continuous  pressure  upon  the 
tumor  is  the  chief  curative  method  and,  if  persisted  in,  it  is  almost  sure 
to  succeed.  Hofmeier 15  has  never  seen  it  fail.  There  are  many  ways 
of  applying  it.  Tyler  Smith, 1G  who  was  soon  followed  by  Teale,  West, 
Bokenthal,  Courty,  etc.,  was  the  first  to  reduce  an  inversion  of  twelve 
years'  duration,  by  the  continuous  pressure  exerted  by  an  air  pessary 
(Gariel's).  One  of  these  can  be  introduced  empty,  and  then  distended 
as  much  as  possible.  Its  action  seems  to  be  exerted  in  many  ways :  by 
direct  pressure  upon  the  tumor  it  diminishes  its  volume;  its  prolonged 
contact  with  the  cervix  serves  to  loosen  it ;  and  finally  the  presence 
of  the  pessary  may  excite  uterine  contractions  which  work  from  below- 
upward  and  help  in  the  reduction.  In  other  countries,  a  colpeurynter, 
a  rubber  bag  filled  with  water,  is  often  used.  It  may  take  a  month  or 
more  to  accomplish  the  reposition,  which  is  usually  preceded  by  sharp 
pain.  Thomas,  Barnes,  Duncan,  Aveling,  etc.,  speak  in  praise  of  a  cup 
and  stem  pessary  wdiich  is  fastened  to  a  belt  by  elastic  bands.  I  con- 
sider it  a  dangerous  instrument  and  one  likely  to  cause  sloughing. 

Tamponade  with  iodoform  gauze  is  far  preferable  to  these  methods, 
as  it  is  simple,  easy  of  application,  and  requires  no  especial  instru- 
ments. It  is  to  be  renewed  every  two  or  three  days,  and  to  be  done 
with  the  utmost  care,  using  long  strips  of  gauze  about  two  fingers' 
breadth  wide,  which  is  packed  around  and  above  the  tumor,  being- 
pressed  in  place  with  some  force.  The  patient  is  to  be  kept  in  a  hori- 
zontal position,  the  bowels  to  be  kept  open  by  enemata,  and,  should 
micturition  be  difficult,  the  catheter  is  to  be  regularly  passed. 

Removal.— A.  few  cases  will  resist  even  a  long-continued  pressure 
treatment.  The  removal  of  the  inverted  portion  of  the  uterus  is  then 
justifiable,  for  the  accidents  caused  by  inversion  often  threaten  life 
itself.  The  history  of  the  methods  used  for  excision  of  the  inverted 
uterus  before  the  days  of  antisepsis  is  as  long  as  it  is  wearisome,  and 
contains  the  oldest  records  of  hysterectomy.17  Amputation  by  means 
of  a  straight  ecraseur ls  is  not  to  be  tolerated.  It  is  a  very  slow  pro- 
cedure, gives  rise  to  agonizing  pain,  does  not  prevent  hemorrhage,  and 
may  wound  neighboring  organs.     Incision  immediately  preceded  by 


528 


CLINICAL   AND    OPEEATIVE   GYNAECOLOGY. 


the  application  of  a  ligature 19  or  a  clamp ; 20  section  by  the  galvano- 
cautery;  slow  ligature  with  iron  wire  or  rubber  tubes  frequently 
tightened,  preceded  by  the  formation  of  a  groove  with  the  thermo- 
cautery (Courty),  are  ancient  methods  which  should  be  obsolete, 
although,  used  properly,  they  are  capable  of  giving  good  results.21 

Perier 22  has  greatly  facilitated  the  application  of  the  slow  ligature 
by  invention  of  his  process  of  elastic  ligation  with  traction,  in  which 
he  uses  a  toothed  ligature  tightener.  Those  practitioners  who  are  not 
familiar  with  the  operation  of  vaginal  hysterectomy  could  utilize  this 
method  with  profit.  Instead  of  applying  the  rubber  cord  directly  to 
the  portion  to  be  excised,  Perier  ties  a  silk  thread  around  the  in- 
verted uterus  and  exerts  traction  upon  this  thread  by  means  of  a  rub- 
ber ring.     The  constricting  band  is  then  constantly  tightened,  by 


Fig.  295. — Forceps  with  Semi- Annular  Jaws  Guarded  by  Rubber  for  Grasping  the  Inverted  Uterus 

(Ferier). 

being  drawn  more  and  more  through  an  opening  at  the  end  of  the 
metallic  holder  which  serves  to  maintain  the  traction.  This  holder 
has  a  toothed  arrangement  at  one  end,  each  tooth  acting  in  its  turn 
as  a  hook  to  hold  the  rubber  ring  as  it  becomes  necessary  to  pull  it 
more  tightly.  The  instruments  necessary  to  the  operation  are :  For- 
ceps to  grasp  and  pull  down  the  uterus  (Fig.  295),  a  toothed  ligature 
holder  (Fig.  296),  strong  silk  thread,  a  rubber  ring,  and  a  hook  (an  or- 
dinary button-hook  will  answer  the  purpose). 

The  uterus  is  first  drawn  down,  the  inversion  being  rendered  com- 
plete if  previously  incomplete,  then  a  loop  of  strong  silk  is  passed 
around  just  above  the  jaws  of  the  forceps,  and  tied  as  tightly  as  pos- 
sible, its  two  ends  being  passed  through  the  eye  of  the  ligature  holder, 
which  is  carried  up  to  the  point  where  the  silk  encircles  the  uterus. 
A  rubber  ring  is  now  fastened  to  the  constricting  band  by  a  second 
knot,  which  it  is  important  to  tie  securely,  since  upon  it  will  come  all 


INVERSION    OF   THE   UTERUS. 


529 


the  strain  when  the  rubber  ring  is  pulled  upon.  With  the  hook  the 
free  side  of  the  rubber  ring  is  seized,  drawn  down,  and  slipped  over 
one  of  the  notches  of  the  handle.  The  uterus  is  allowed  to  return  to 
its  former  position  in  the  vagina,  and  the  handle  of  the  ligature 
holder  emerges  from  the  vulva  without  exercising  any  pressure  upon 
the  soft  parts,  being  held  in  the  axis  of  the  vagina.  Upon  the  days 
following  the  operation,  the  rubber  ring  may  be  drawn  over  notches 
farther  and  farther  removed  from  the  uterus,  thus  progressively  tight- 
ening the  ligature.  Between  the  ninth  and  the  fourteenth  day,  the 
uterus  becomes  detached,  a  shrivelled  and  unrecognizable  mass.  An- 
tiseptic vaginal  injections  should  be  used  twice  daily. 

Kaltenbach23  advises  the  immediate  amputation  of  the  inverted 
portion  of  the  uterus,  after  the  application  of  a  temporary  elastic  liga- 


Fig.  296.— Ligature  Holder  Used  in  Removal  op  the  Inverted  Uterus  by  Perier's  Method. 


ture.  As  a  precautionary  measure,  and  to  prevent  any  possible  slip- 
ping of  this  ligature,  the  peritoneal  surfaces  may  then  be  joined  by 
deep  sutures  passing  obliquely  under  the  surface  of  the  stump  in  such 
a  way  as  at  the  same  time  to  compress  the  blood-vessels.  The  stump 
may  be  dressed  with  iodoform  or  sublimate  gauze,  and  will  fall  about 
the  third  week,  by  which  time  the  two  peritoneal  surfaces  are  quite 
united,  which  will  prevent  the  formation  of  any  vagino-peritoneal 
fistula,  which  might  lead  to  an  extra-uterine  pregnancy.  If  the  pedicle 
is  very  large,  a  double  elastic  ligature  can  be  applied  by  transfixion. 
The  technical  details  of  total  extirpation  of  the  uterus  through 
the  vagina  have  been  so  accurately  tested,  and  the  operation  has  given 
such  excellent  results  (page  360),  that,  for  my  part,  if  reduction  were 
not  possible,  I  should  not  hesitate  to  perform  it  rather  than  an  ampu- 
tation limited  to  the  inverted  portion. 
34 


530  CLINICAL   AND    OPERATIVE   GYNECOLOGY. 


BIBLIOGRAPHY. 

1.  Rokitansky,  cited  by  Hart  and  Barbour:  Manuel  de  Gyn.,  French  ed.,  1886, 
p.  411. 

2.  Crosse:  An  Essay,  Literary  and  Practical,  on  Inversio  Uteri.  Transact. 
Provinc.  Med.  and  Surg.  Association,  London,  1845. 

3.  W.  W.  Jaggard  (Gynec.  Soc.  of  Chicago,  November  19th,  1886,  reviewed  in 
Centr.  f.  Gyn.,  1887,  p.  402)  reports  a  case  where  an  inversion  dating  from  confine- 
ment was  overlooked,  and  the  symptoms  attributed  to  the  puerperal  state,  the 
physicians  having  actually  refrained  from  examining  the  patient  from  the  fear  of 
infecting  her. 

4.  Homolle  and  Martin:  Ann.  de  Gyn.,  1875. 

5.  MacClintock  (Diseases  of  Women,  Dublin,  1863,  p.  97)  gives  an  example; 
Schrdder  (Mai.  des  Org.  de  la  Feinine,  French  ed.,  1886,  p.  220)  gives  one  also. 
Barber:   Case  of  Inversion  of  the  Uterus  with  complete  Prolapse.     Lancet,  1887, 

vol.  hi.,  p.  660. 

6.  Leprevost:  Inversion  Utenne  Irr6ductible,  etc.  Tillaux's  report:  Bull.  Soc. 
de  Chirurgie,  June,  1888,  p.  503.  Berger  and  Ribeniont  (Annales  d'Hygiene  et  de 
Medecine  Legale,  1882,  vol.  viii. ,  p.  321)  proved  by  experimentation  at  Lourcine 
that  the  uterine  mucous  membrane  is  normally  insensitive. 

7.  Spiegelberg:  Arch.  f.  Gyn.,  Ed.  iv.,  p.  350  and  Bd.  v.,  p.  118. 

8.  R.  Teuffel  (Centr.  f.  Gyn.,  No.  25,  1888)  reports  a  great  success  by  means  of 
this  manoeuvre  which  he  rates  very  highly. 

9.  Audige:  Paris  Thesis,  1881. 

10.  These  manoeuvres  are  always  attended  by  some  degree  of  danger;  the  va- 
gina has  often  been  torn  by  the  efforts  of  taxis.  T.  P.  Teale:  Chronic  Inversion  of 
the  Uterus  reduced  by  Taxis;  Laceration  of  Vagina  into  Douglas'  Pouch;  Recovery. 
Lancet,  1887,  vol.  L,  p.  11. 

11.  Emmet:  Principles  and  Practice  of  Gyn.,  1880,  pp.  410-437. 

12.  Courty :  Trait6  Pratique  des  Mai.  de  l'Uterus,  3d  ed.,  1881,  p.  730.  Chauvel: 
Bull.  Soc.  de  Chir.,  1879,  p.  352. 

13.  Thomas:  Dis.  of  Women,  1872,  p.  434. 

14.  Bouilly:  Encyclop.  Internat.  de  Chirurg.,  French  ed.,  vol.  vii.,  p.  689. 
Mund<§  (Laparatomy  for  Reduction  of  an  Inverted  Uterus,  in  American  Journal 
of  Obstetrics,  1888,  vol.  xxi.,  p.  1,279),  after  having  tried  in  vain  to  reduce  a  case  of 
chronic  inversion,  decided  to  perform  a  laparatomy  and  dilate  the  cervix  from 
above,  according  to  Thomas'  method.  Not  succeeding  in  this,  he  performed  ovari- 
otomy and  removal  of  the  uterus  With  an  elastic  ligature.     A  cure  followed. 

15.  Hofmeier:  Grand,  der  gyn.  Oper.,  p.  239,  1888. 

16.  Tyler  Smith:  Med.  Times  and  Gazette,  April  24th,  1858. 

17  Two  curious  cases  are  found  in  Rosset's  celebrated  work,  Csesarei  Partus 
Assertio  Historiologica,  Paris,  1590,  p.  332.  After  ligating  the  uterus,  he  excised 
the  inverted  portion  and  then  cauterized  the  stump  with  a  red-hot  iron.  One  of 
the  cases  occurred  in  1533.  Both  patients  recovered.  I  have  brought  together 
many  of  these  historical  facts  in  a  thesis  entitled,  Sur  la  Valeur  de  l'Hysterotoinie, 
1875,  p.  149.     See  also  Denuc<5:  Traits  de  l'lnversion  Utenne,  Paris,  1883. 

18.  Aran:  Lecon  Cliniques  sur  les  Mai.  de  l'Uterus,  Paris,  1858,  p.  914.  Mac- 
Clintock: Loc.  cit.  (5),  p.  85.  Sims:  Uterine  Surgery,  London,  1865,  p.  155.  V. 
Faucon:  Sur  une  Forme  Particuliere  d'lnversion  Polypeuse  de  l'Uterus,  Inver- 
sion Sup<5ro-lat6rale,  Amputee  par  le  l'ecraseur  Lineaire  avec  Suture.  Bull,  de 
FAcad.  Roy.  de  Belgique,  1887,  pp.  723-738. 

19.  Palasciano,  quoted  by  Courty:  Loc.  cit.  (12),  p.  736. 


INVEBSION    OF   THE    UTEEUS.  531 

20.  Valette  (of  Lyons):  Lyon  Medical,  1871. 

21.  Le  Fort:  Inversion  Uterine;  Ligature  Elastique:  Gruerison.  Bulletin  Soc. 
de  Chirurgie,  1887,  p.  201.  A  piece  of  rubber  cord  was  wound  seven  or  eight  times 
around  the  pedicle,  and  below  this  ligature  was  placed  another  of  ordinary  thread. 
No  excision  of  the  tumor;  at  the  end  of  thirteen  days  the  ligature  came  away.  A 
cure  resulted. 

22.  Pener:  Bull.  Soc.  de  Chirurg.,  June  16th.  1880.  De  la  Ligature  a.  Traction 
Elastique  Appliquee  au  Traitement  de  Flnversion  Uterine.  Revue  de  Chirurgie, 
December,  18SG.  Le  Fort:  Inversion  Uterine:  Ligature  Elastique:  Guerison.  Bull. 
Soc.  de  Chirurgie,  1887,  201.  Leprevost:  Inversion  Uterine  Deductible;  Amrmta- 
tion  de  1' Uterus  par  la  Ligature  a  Traction  Elastique:  Guerison.  Rapport  de  Til- 
laux:  Bull.  Soc.  de  Chir.,  1888,  p.  503. 

23.  Hegar  and  Kaltenbach:  Die  Operative  Gynak.,  3d  ed.,  1886,  p.  572.  Hig- 
guet  (Bull,  de  la  l'Acad.  Roy.  Belgigue.  1885,  p.  500)  reports  a  successful  result 
obtained  by  double  elastic  ligature,  followed  by  excision  by  means  of  the  galvano- 
cautery.  Goossens  (of  Rotterdam)  (Centr.  f.  Gyn..  1887,  No.  37)  amputated  the 
uterus  just  below  an  elastic  ligature,  with  a  successful  result. 


CHAPTER  XXI. 

MALFORMATIONS   OF    THE    OEEVIX— ATRESIA.     STENOSIS. 
ATROPHY.     HYPERTROPHY. 

Atresia. 

By  atresia  of  the  cervix  we  mean  that  the  os  uteri  is  imperforate 
or  occluded. 

Congenital  atresia x  is  in  the  great  majority  of  cases  found  only 
as  accompanying  other  and  graver  malformations,  as  double  uterus 
and  vagina,  whose  description  belongs  to  the  general  history  of  mal- 
formations of  the  genital  organs.  Theoretically  we  should  here  include 
a  description  of  those  rare  but  incontestably  existing  cases  where  the 
only  congenital  lesion  has  seemed  to  be  an  imperforate  cervix,  the 
occlusion  being  either  at  the  internal  or  the  external  os,2  but  as  the 
clinical  results  of  this  anomaly  are  identical  with  those  of  absence  of 
development  of  the  upper  portion  of  the  vagina,  its  description  would 
involve  needless  repetition. 

Acquired  atresia*  follows  sloughing  after  labor,  cicatrices  result- 
ing from  excessive  cauterization  of  the  whole  periphery  of  the  cervix, 
amputations  which  have  not  resulted  iu  lining  the  circumference  of 
the  cervical  opening  with  mucous  membrane  but  have  permitted  a 
concentric  retraction  of  the  modular  tissue.  It  may  also  follow  the 
cicatrization  of  ulcers  of  the  cervix  coincident  with  senile  atrophy  of 
the  uterus ;  finally  it  may,  in  old  women,  be  due  to  a  tumor  in  the 
cervix  or  lower  portion  of  the  body  of  the  uterus.  Atresia  also  occurs, 
in  prolapsus  uteri,  as  a  result  of  the  friction  of  a  pessary  or  of  the 
thighs  upon  the  os  if  there  be  complete  prolapse.  It  may  occur 
spontaneously  in  old  age;  and  some  cases,  to  my  mind  of  doubtful  oc- 
currence, have  been  reported  of  atresia  appearing  during  pregnancy.4 

The  results  of  this  obliteration  vary  as  the  patient  has  or  has  not 
reached  the  menopause.  If  not,  we  must  be  on  our  guard  against 
haBmatometra  and  hsemato-salpinx  (see  chapter  on  Malformations).  If 
she  have  ceased  menstruating,  the  lesion  usually  causes  no  disturb- 
ance unless  some  cause  of  septic  infection  exist  in  the  uterine  cavity 


MALFORMATIONS   OF   THE   CERVIX. 


533 


causing  an  accumulation  of  pus  (pyometra)  or  gas  (physometra).  I 
have  seen  two  cases  of  pyometra  from  cancer  of  the  body  of  the  uterus 
and  fibroma  in  aged  women.  The  treatment  in  such  a  case  consists 
in  incising  or  puncturing  the  cervix  if  it  be  necessary  to  disinfect  the 
uterine  cavity,  and  then  in  meeting  the  indications  called  for  by  an 
existing  fibroma  or  cancer. 


Stenosis. 

Stenosis  is  a  narrowing  of  the  cervical  canal,  which  may  be  congen- 
ital or  acquired.     When  congenital,  it  is  usually  accompanied  by  a 


Fig.  297. — Cervical  Stenosis — Various  Forms  op  Conical  Cervix. 

conical  cervix,  often  hypertrophied  in  inverse  proportion  to  the  devel- 
opment of  the  body  of  the  uterus.  The  conical  or  sugar-loaf  cervix 
is  firm  in  consistency  and  has  at  its  apex  a  pin-hole  os  (Fig.  299). 
The  anterior  lip  may  protrude  a  little,  giving  the  appearance  of  hypo- 
spadias of  the  canal,  or  it  may  resemble  the  trumpet-shaped  snout  of 
a  tapir,  in  which  case  the  stenosis  is  usually  accompanied  by  congen- 
ital hypertrophy  of  the  cervix  (Fig.  297).  Congenital  stenosis  may  be 
the  result  of  an  anteflexion  of  the  uterus,  pronounced  enough  to 
obliterate  the  cervical  canal.  Acquired  stenosis  is  due  to  the  same 
causes  as  atresia.  One  of  the  consequences  of  the  narrowing  is  the 
retention  of  the  cervical  mucus,  which  accumulates,  and  dilates  the 
cavity  of  the  cervix.     Catarrhal  inflammation  of  the  mucous  mem- 


534 


CLINICAL  AND  opeeative  gynecology. 


brane  follows,  causing  an  increased  secretion  of  discolored,  tenacious, 
viscid  mucus  (Fig.  298).  The  use  of  speculum  and  uterine  sound  will 
speedily  decide  the  question  of  the  existence  of  this  condition ;  when 
the  sound  lias  passed  the  os,  it  enters  an  ampulla-like  dilatation  of  the 
cervical  cavity. 

Dysmenorrhcea  and  sterility  are  the  two  more  prominent  symp- 
toms, though  in  some  cases  dysmenorrhcea  is  absent. 

The  pain  experienced  during  menstruation,  the  obstructive  dys- 
menorrhcea of  English  writers,  is  usually  situated  in  the  lumbo-iliac 
and  sacral  regions ;  it  is  colicky  in  its  nature,  coming  on  spasmodically, 
when  the  amount  of  blood  exuded  is  too  great  to  be  immediately  car- 


Fig.  298.— Cervical  Stenosis.  Dilatation  of  the 
cavity  of  the  cervix  by  retention  of  mucus,  in  a  case 
of  cervical  endometritis  with  narrowing  of  the  ex- 
ternal os. 


Fig.  299.— Cervical  Stenosis.  Uterus  with  nar- 
row cervical  canal,  without  flexion.  (Typical  case 
for  Simpson's  operation.) 


ried  through  the  narrowed  canal,  or  when  the  cervix  is  obstructed  by 
a  clot.  Relief  follows  a  breaking  of  the  clot.  The  pain  is  frequently 
so  intense  that  the  patients  develop  marked  nervous  reflexes,  as  syn- 
cope or  uncontrollable  vomiting,  which  leave  them  in  a  condition  of 
extreme  prostration.  These  patients  are  usually  chlorotic,  anaemic, 
dyspeptic,  and  neuropathic.  Endometritis  frequently  results  from  the 
imperfect  evacuation  of  the  mucus  and  blood  from  the  uterine  cavity 
and  the  group  of  uterine  symptoms  then  persists  in  the  intervals  be- 
tween the  menstrual  periods.  This  is  a  frequent  form  of  the  endome- 
tritis of  virgins. 

Stenosis  oftentimes  causes  sterility,  although  its  influence  in  this 
particular  has  been  exaggerated  since  the  days  of  Sims.     The  mechan- 


MALFORMATIONS    OF   THE   CEEVIX.  535 

ical  obstruction  to  the  entrance  of  the  spermatic  fluid  is  a  less  im- 
portant factor  than  the  mucous  congestion  of  the  cervical  canal. 
Normally,  during  coition,  the  cervix,  by  a  species  of  erethism  which 
Rouget  has  compared  to  true  erection,  expels  the  mucus  which  it  con- 
tains.5 From  aspiration  succeeding  the  cessation  of  the  venereal 
orgasm,  or  simply  from  capillarity,  the  alkaline  vaginal  mucus  mixed 
with  spermatic  fluid  enters  the  cervix  in  its  place.6  This  exchange  is 
prevented  by  the  narrowness  of  the  external  aperture,  which  is  com- 
pletely stopped  up  by  a  plug  of  acid  mucus. 

Diagnosis. — The  most  interesting  and  delicate  point  of  diagnosis 
consists  in  localizing  the  exact  point  of  maximum  of  constriction. 
Where  there  is  a  conical  cervix  with  a  pin-hole  os  hidden  by  a  drop 
of  viscid  mucus  not  unlike  the  small  concrete  masses  of  sputum  from 
the  larynx,  the  external  os  is  without  doubt  one  of  the  points  at  fault. 
But  it  may  not  be  the  only  one;  for  as  Bennett  justly  remarks,  there  is 
normally  another  narrow  opening  at  the  upper  end  of  the  cervix  which 
may  be  constricted  (Fig.  299). 

Stenosis  of  the  internal  os  has  been  said  to  be  due  to  contracture, 
but  I  consider  this  doubtful.  It  seems  to  me  to  be  the  result  of  in- 
complete development,  with  or  without  congenital  anteflexion.  Ac- 
quired stenosis  from  excessive  cauterization  is  more  rare  at  the  inter- 
nal than  the  external  os,  and  worthy  of  passing  mention  only. 

If  difficulty  is  experienced  in  passing  the  sound  through  the  inter- 
nal os,  we  must  not  jump  to  the  conclusion  that  there  is  necessarily  a 
constriction  at  this  point.  We  must  first  be  certain  that  the  tip  of 
the  sound  has  not  come  against  a  fold  of  mucous  membrane  or  the 
angle  of  a  flexion ;  and  to  ascertain  if  this  be  so,  we  bend  the  sound  in 
accordance  with  the  presumed  direction  of  the  cervico-uterine  canal, 
press  down  the  handle  toward  the  fourchette,  and  draw  down  the 
posterior  lip  of  the  cervix  in  the  case  of  an  anteflexion,  and  the  ante- 
rior lip  in  case  of  a  retroflexion.  We  must  grope  gently  with  the 
sound  a  great  many  times  before  the  diagnosis  can  be  established  with 
certainty. 

Prognosis. — Congenital  cervical  stenosis,  which  is  the  most  fre- 
quent form,  disappears  after  fecundation  and  labor,  not  so  much  from 
the  excessive  dilatation  as  from  the  structural  changes  undergone  by 
the  uterus  in  pregnancy.  The  efforts  of  the  surgeon  should  be  directed 
toward  favoring  fecundation,  and  the  various  methods  of  artificial 
dilatation  are  to  be  regarded  as  merely  temporary  and  palliative. 

Treatment. — Slow  dilatation  with  laminaria  tents,  or  rapid  pro- 


536 


CLINICAL   AXD    OPERATIVE   GYNAECOLOGY. 


gressive  dilatation  with  graduated  bougies,  gives  merely  ephemeral 
results,  yet  it  may  be  used  to  advantage  before  each  menstrual  period. 
T  prefer  Hegar's  dilating  bougies,  and  believe  that  their  frequent  use 
may  stimulate  the  vitality  of  a  more  or  less  incompletely  developed 
uterus  (for  details,  see  page  112  et  seq.). 

This  operation,  although  a  minor  one,  must  be  considered  worthy 


Fig.  300. — Cervical  Stenosis.    Normal  and  pin-hole  os. 

of  antiseptic  precautions.  Some  serious  accidents  have  been  known 
to  follow  it,  and  doubtless  a  greater  number  still  have  not  been  re- 
ported.7 

Division  of  the  external  os  may  be  done  with  a  bistoury,  with 
strong  scissors,  with  Kuchenmeister's  scissors  (which  have  hooked 


Fig.  301. — Discission  of  the  Cervical  Canal.  1, 
Division  by  Kuchenmeister's  scissors  ;  2,  Division 
with  a  double  hysterotome.  The  dotted  line  A,  B,  C. 
indicates  the  segment  incised  by  the  separation  of 
the  blades. 


Fig.  302. — Stenosis  of  the  Cervical  Canal. 
Line  of  incision  at  the  internal  os ;  a,  incision  of 
the  external  os  on  a  level  with  the  posterior  lip  ; 
b.  incision  of  the  internal  os  on  a  level  with  the 
anterior  wall. 


ends  to  prevent  slipping),  or  with  some  one  of  the  many  forms  of 
hysterotome  which  have  been  invented  since  Simpson8  first  recom- 
mended this  operation.  Marion  Sims 9  made  great  use  of  this  method 
of  treatment,  and  brought  it  into  a  prominence  which  is  at  this  day 
hard  to  understand  from  an  exclusively    scientific   point   of  view. 


MALFORMATIONS   OF   THE   CERVIX.  537 

Since  his  time  gynaecology  has  passed  through  a  period  when  discission 
of  the  cervix  was  carried  to  an  extreme.  Any  young  wife  in  whom 
pregnancy  was  a  trifle  delayed,  any  young  girl  or  woman  suffering 
during  menstruation,  was  considered  a  fit  subject  for  this  operation. 
Now,  however  unimportant  it  may  seem  to  be,  it  has  most  certainly 
led  to  fatal  results,  especially  before  the  days  of  antisepsis. 

We  must  distinguish  between  section  of  the  external  os  (which 
may  be  median,  posterior,  bilateral,  or  crucial)  and  an  incision  which 
is  carried  into  the  cervical  canal  and  to  the  internal  os  (Fig.  302). 
The  incisions  may  be  made  with  a  probe-pointed  bistoury,  after  draw- 
ing the  cervix  down  and  steadying  it.  This  operation  is  far  more 
serious  than  the  one  first  mentioned.  To  arrest  hemorrhage,  the 
wound  may  be  loosely  tamponed  with  small  pledgets  of  cotton  soaked 
in  perchloride  of  iron,  which  are  to  be  taken  out  on  the  following 
day.  The  patient  should  be  kept  three  days  in  bed.  Barnes'  small 
elastic-stem  pessary  or  Thomas'  glass  stem  may  be  worn  for  several 
days  in  the  cervix.10 

I  do  not  describe  these  operations  in  detail,  because  I  consider  them 
bad  practice.  Incisions  of  the  external  os  either  by  cicatrization  cause 
stenosis  again,  or  by  gaping  cause  an  eversion  of  the  mucous  membrane 
and  consequent  cervical  catarrh.  The  deeper  incisions  are  not  unat- 
tended by  danger,  for,  however  carefully  one  may  use  the  hysterotome, 
the  instrument  with  which  we  are  working  in  the  dark  may  easily 
slip  and  cause  serious  accidents.  I  much  prefer  the  probe-pointed 
bistoury,  which  is  more  manageable. 

Dilatation  of  the  cervix  by  either  the  bloodless  or  bloody  opera- 
tions may  give  excellent  results  in  those  cases  where  the  stenosis  is 
slight  and  accompanied  by  quite  disproportionate  nervous  reflex  phe- 
nomena. However,  two  opposite  theories  have  been  advanced  in  re- 
gard to  this  subject.  Schauta,  who  advocates  incision,  claims  to  have 
cured  hysterical  neuroses  by  the  section  of  nerve  filaments;  he  states 
that  in  such  cases  dilatation  by  the  bloodless  method  is  of  no  avail.11 
On  the  other  hand,  Doleris  recommends  forced  dilatation  of  the  cer- 
vix nnder  the  same  circumstances,  claiming  that  it  acts  in  the  same 
way  as  nerve-stretching.12  It  seems  to  me  that  the  relief  afforded  by 
both  of  these  methods  may  be  fully  explained  by  the  ready  flow  of 
previously  retained  mncus,  which  removes  a  source  of  continual  reflex 
action.     Gastric  troubles  as  well  as  pain  are  rapidly  relieved.13 

Electrolysis 14  has  been  highly  praised.  The  advantages  claimed 
for  it  are,  its  harmlessness  and  painlessness  and  its  efficacy  due  to 


538  CLINICAL   AND    OPERATIVE   GYNECOLOGY. 

the  fact  that  the  slough  produced  by  the  negative  pole  leaves  a 
cicatrix  as  soft  and  distensible  as  that  produced  by  alkaline  caustics. 
Currents  of  feeble  strength  but  long  duration  are  recommended. 

In  cases  of  slight  stenosis  I  prefer  the  simpler  method  of  gradual 
dilatation  with  Hegar's  bougies  (after  softening  the  cervix  with  lamina- 
ria).  I  sometimes  combine  this  treatment  with  very  small  incisions 
upon  the  circumference  of  the  os  with  a  probe-pointed  tenotome  to 
facilitate  the  insertion  of  the  laminaria. 

In  cases  of  marked  stenosis,  the  only  rational  operation  seems  to 
me  to  be  a  plastic  operation  for  the  production  of  an  external  orifice 
of  sufficient  size.  The  operation  of  stomatoplasty  does  not  affect  the 
external  os  only,  as  one  might  imagine.  By  the  functional  changes 
which  it  induces  in  the  cervix,  the  upper  portion  of  the  canal  becomes 
more  permeable.  There  are  cases  where  a  flexion  of  the  uterus  gives 
the  impression  of  a  constriction  situated  high  in  the  cervix.  This  flex- 
ion often  disappears  after  the  operation,  so  that  I  consider  it  advisable 
to  wait  a  while  before  attempting  to  treat  a  suspected  stenosis  of  the 
upper  portion  of  the  canal  which  has  been  diagnosed  by  anterior  pal- 
pation. Later,  should  the  stenosis  persist,  gradual  dilatation  with 
Hegar's  bougies  is  preferable  to  incision,  though  a  few  slight  scari- 
fications may  be  made  to  facilitate  the  passage  of  the  first  bougies,  but 
these  do  not  in  the  least  resemble  the  deep  discission  of  Simpson, 
Sims,  etc. 

Stomatoplasty  is  in  reality  nothing  more  nor  less  than  amputation 
of  the  cervix.  I  have  minutely  described  it  in  the  chapter  upon  the 
Treatment  of  Metritis  (p.  207).  According  to  the  case,  one  may  choose 
one  or  the  other  process  described.  If  the  cervix  is  thick  and  fleshy, 
the  biconical  excision  (of  Simon-Marckwald)  is  to  be  preferred.  If  the 
mucous  membrane  has  undergone  profound  alteration,  the  single 
flap  operation  of  Schroder  is  the  better.  I  have  sometimes  combined 
the  two  methods  where  the  cervix  was  conical,  taking  a  wedge-shaped 
piece  from  the  anterior  lip,  but  paring  only  one  surface  on  the  posterior 
lip.  Whatever  method  be  adopted,  the  result  aimed  at  is  the  forma- 
tion of  a  transverse  opening  of  ample  size,  with  the  mucous  mem- 
brane lining  it  to  the  very  edge  in  such  a  way  that  it  will  not  con- 
tract after  the  o£>eration. 

Congenital  Atrophy  of  the  Cervix  and    Uterus. 

There  is  a  so-called  congenital  atrophy  to  which  it  would  be  better 
to  apply  the  term  congenital  predisrjosition  to  atrophy,  for  after  birth 


MALFORMATIONS    OF   THE    CERVIX.  539 

the  uterus  may  experience  a  general  retardation  of  growth  which 
cannot  properly  be  called  an  arrest  of  development  like  that  which 
occurs  in  prenatal  life — an  arrest  which  would  produce  a  malforma- 
tion either  by  the  excess  or  absence  of  some  portion  of  the  organ — 
this  general  retardation  resulting  in  an  adult  uterus  of  infantile  pro- 
portions but  unaltered  in  its  type.  The  whole  organ  is  small  and 
its  walls  thin,  but  the  relative  proportions  of  body  and  cervix  are  nor- 
mal, thus  differing  from  the  foetal  uterus.  This  type  Puech  calls  a 
uterus  pubescens,  to  show  that  it  preserves  the  proportions  found 
at  puberty.  Yirchow  calls  it  hypoplasia  of  the  uterus..  As  a  usual 
thing,  it  is  accompanied  by  atrophy  of  the  other  internal  and  exter- 
nal organs  of  generation.  According  to  Puech, 1S  the  uterus  pubescens 
weighs  about  405  grains  instead  of  675. 

This  infantile  condition  cf  the  genital  organs  is  often  accompanied 
in  the  female  (as  in  the  male)  by  a  general  lack  of  development,  a 
young  woman  of  -twenty  years  and  more  having  the  appearance  of  a 
child  who  has  not  yet  reached  puberty.  In  other  cases,  the  atrophy 
is  limited  to  the  sexual  apparatus,  and  there  are  no  external  signs  of 
it  visible  except  a  narrowness  of  the  pelvis.  There  is,  in  fact,  with 
rare  exceptions,  an  intimate  relation  between  this  part  of  the  bony 
framework  and  the  internal  genital  organs.  Atrophy  is  to  be  at- 
tributed to  a  congenital  predisposition  of  unknown  origin.  It  has 
been  supposed  to  be  due  to  chlorosis  or  tuberculosis,  but  it  seems  to 
me  that  cause  and  effect  have  been  reversed,  the  women  with  this 
malformation  possessing  a  defective  nervous  system  and  general  in 
nutrition  because  of  the  genital  lesion. 

Symptoms  and  Diagnosis. — Complete  or  partial  amenorrhcea  is 
the  first  thing  noticed  by  the  patient.  The  menses  may  fail  to  appear 
and  the  patient  be  sexless  from  a  physiological  standpoint.  If  they 
do  appear,  they  are  usually  accompanied  by  dysmenorrhea  and 
serious  nervous  symptoms.  Some  of  the  patients  inherit  a  defective 
nervous  system,  and  belong  to  the  neurotic  class  called  degeneres  by 
the  alienists ;  they  possess  a  feeble  intellect,  and  have  hysterical  or 
epileptic  seizures.  This  is  not,  however,  a  general  rule,  for  another 
class  of  patients  with  a  uterus  pubescens  have  a  vigorous  constitution 
in  every  other  respect.  Local  examination  reveals  a  small  cervix  with 
a  narrow  os;  bimanual  palpation,  rectal  touch,  the  passage  of  the 
sound,  all  show  atrophy  of  the  uterus  itself;  the  external  genitals  are 
usually  incompletely  developed;  the  vagina  is  shorter  than  usual. 
The  normal  proportion  of  the  cervix  in  uterus  pubescens  distinguishes 


540  CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 

it  from  the  foetal  or  infantile  uterus  *  where  the  cervix  is  large  and 
the  body  atrophied. 

Treatment  should  be  at  first  directed  to  the  general  condition. 
Tonics,  nourishment,  hydrotherapy,  sea  air,  all  tend  to  improve  the 
health  and  favor  development.  As  to  local  treatment,  there  is  scarcely 
any  of  value.  It  has  been  suggested  that  pessaries  with  galvanic 
stems  of  iron  and  copper  might  induce  feeble  electric  currents  and 
act  as  local  stimulants,  but  this  method  is  not  without  difficulties 
and  dangers,  and  a  good  result  is  by  no  means  certain.  It  would  be 
far  more  rational  to  apply  electricity  directly,  using  a  continuous 
current.  Symptomatic  treatment  should  be  directed  to  the  dysmen- 
orrhea. If  this  be  very  severe  and  the  nervous  symptoms  marked, 
it  would  be  reasonable  to  suppose  that  the  development  of  the  ovaries 
was  out  of  proportion  to  that  of  the  uterus ;  if  an  examination  under 
chloroform  established  this  fact,  ovariotomy  might  be  indicated.16 

Acquired  Atrophy,  or  Superinvolution  of  the  Cervix  and  Body 

of  the  Uterus. 17 

Pathological  Anatomy  and  Etiology. — Normally,  the  termina- 
tion of  sexual  functions  in  the  female  is  marked  by  a  shrinking  in 
size  of  the  uterus,  which  is  progressive,  so  that  in  aged  women  the 
uterus  is  extremely  small,  unless,  as  frequently  occurs,  it  contain  a 
fibroid  body. 

Senile  atrophy  affects  both  body  and  cervix,  the  latter  being  often 
only  a  shapeless  stump,  or  even  disappearing  entirely  with  the  ex- 
ception of  the  os,  which  is  seen  at  the  end  of  the  vagina.  This  occurs 
most  often  in  women  who  have  borne  many  children.  Atrophy 
sometimes  begins  before  the  menopause,  after  a  labor  which  seems 
suddenly  to  exhaust  the  vitality  of  the  uterus,  the  normal  involution 
being  carried  beyond  physiological  limits.  James  Simpson18  esti- 
mates the  occurrence  of  this  atrophy  at  about  1.5  per  cent,  and  From- 
mel 19  at  lfc  But  these  superinvolutions  are  sometimes  only  temporary 
in  duration.  Frommel  considers  prolonged  lactation 20  as  one  of  the 
principal  causes  of  atrophy.  Profuse  hemorrhages  during  labor  seem 
to  exert  a  predisposing  influence,  as  do  all  debilitating  diseases— 

*  This  second  term  must  not  be  misunderstood.  It  is  derived  from  infans,  and 
means  properly  a  foetus  at  term.  The  name  puerile  or  childish  might  be  applied 
to  the  uterus  pubescens,  indicating  that  it  is  analogous  to  that  of  a  child  (before 
puberty). 


MALFORMATIONS   OF   THE   CERVIX.  541 

tuberculosis,  chlorosis,  syphilis,  diabetes,21  Bright's  disease,  morphin- 
ism, Basedow's 22  disease,  etc.  Diseases  of  the  genital  organs,  as  pro- 
longed endometritis  and  oophorosalpingitis  often  terminate  by 
atrophy. 

Pelvic  peritonitis  during  the  puerperal  period,  or  rather  the  septic 
peri-oophoro-salpingitis  which  sometimes  follows  labor  or  abortion, 
may,  by  causing  sclerosis  of  the  ovary,  bring  on  a  premature  meno- 
pause and  superinvolution.  Finally,  I  have  noted  that  the  diminution 
in  volume  of  the  body  of  the  uterus,  which  Braun23  observed  to 
follow  amputation  of  the  cervix,  may  go  on  to  atrophy  of  the  uterus. 
In  an  old  woman  upon  whom  four  years  ago  I  performed  a  con- 
oidal  amputation  of  the  cervix,  according  to  Huguier's  method,  for 
prolapsus,  the  uterus  has  become  reduced  to  the  size  of  a  walnut.  In 
the  case  of  a  young  woman  where  I  excised  a  portion  of  the  cervical 
mucous  membrane  for  severe  endometritis,  the  uterus  was  for  a  time 
greatly  diminished  in  size,  but  finally  returned  to  its  normal  condition. 

[Hardon  u  has  noted  nine  cases  and  Hawkins  two  where  superin- 
volution  occurred  after  the  closure  of  a  lacerated  cervix  by  Emmet's 
operation.  In  eight  of  these  eleven  cases  which  were  treated  by 
intra-uterine  faradization  the  menses  returned,  while  in  three  which 
received  no  treatment  the  condition  persisted.] 

Removal  of  tlie  ovaries  is  a  cause  of  uterine  atrophy,  and  some 
authorities 25  have  not  hesitated  to  perform  an  ovariotomy  for  the  cure 
of  persistent,  painful  endometritis. 

In  senile  atrophy,  the  uterine  tissue  is  sclerotic ;  in  post-puerperal 
superin volution  it  may  be  soft  and  friable  from  incomplete  absorption 
of  the  fatty  substances  produced  by  the  disintegration  of  the  muscu- 
lar fibres.26 

Symptoms  and  Diagnosis. — The  cessation  of  the  menses  and  the 
diminution  in  volume  of  the  cervix  and  body  of  the  uterus,  as  proved 
by  the  various  methods  of  exploration,  establish  the  diagnosis.  The 
greatest  caution  should  be  exercised  in  the  use  of  the  sound  in  post- 
puerperal  atrophy,  as  the  walls  may  be  thinned.  In  cases  of  senile 
atrophy,  the  sound  can  penetrate  only  to  the  depth  of  about  two  to 
two  and  a  quarter  inches,  while  in  puerperal  superinvolution  the 
cavity  is  usually  normal,  but  may  seem  to  be  deepened  from  the  yield- 
ing nature  of  the  uterine  tissues. 

Prognosis  and  Treatment— -This  post-puerperal  superinvolution 
maybe  only  temporary  in  its  nature;  and  the  observation  of  many 
cases  has  gone  to  prove  that  fecundation  and  pregnancy  may  after- 


542 


CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 


ward  take  place.  A  return  of  the  functional  activity  of  the  uterus 
should  be  aided  by  general  tonics,  hydrotherapy,  salt  baths,  the  intra- 
uterine application  of  electricity,  and  local  stimulation  produced  by 
hot  injections  and  the  often-repeated  passing  of  the  sound  into  the 
uterine  cavity.  I  prefer  these  methods  to  the  use  of  a  galvanic  or 
elastic  stem  pessary,  which  seem  to  me  to  play  the  harmful  part  of  a 
foreign  body  rather  than  to  benefit. 


Hypertrophy  of  the  Supra-vaginal  Portion  of  the  Cervix. 

Hypertrophy  may  affect  the  snpra-  or  the  intra-vaginal  portion  of 
the  cervix.    I  have  already  described  the  first  lesion  under  the  head 


Fig.  303.— Hypertrophy  op  the  Supra- Vaginal  Portion  of  the  Cervix. 

of  Prolapse  of  the  Genital  Organs,  which  it  so  frequently  accompanies. 
Polaillon27  records  a  case  where  both  the  supra-vaginal  portion  of 
the  cervix  and  the  body  of  the  uterus  had  undergone  a  gigantic  hy- 
pertrophy; the  uterus,  which  was  not  altered  in  shape  and  in  which 
there  was  no  tumor,  filled  the  whole  abdomen.  The  patient  was  thirty 
years  old;  etiology  unknown;  symptoms  of  endometritis  present. 
Polaillon  advised  injections  of  ergotin  into  the  substance  of  the  uterus, 
the  continuous  electric  current,  and,  as  a  last  resort,  ovariotomy. 
These  exceptional  cases  of  a  gigantic  uterus  could  not  be  mistaken 


MALFORMATIONS    OF   THE   CERVIX. 


543 


for  hypertrophy  of  the  supra-vaginal  portion  of  the  cervix.  The  hy- 
pertrophy following  upon  the  presence  of  hbrous  body  or  "  grossesse 
fibreuse"  could  also  be  easily  recognized  by  the  special  symptoms 
caused.  The  only  symptom  common  to  all  of  these  conditions  is  the 
unwonted  depth  to  which  the  sound  may  be  carried. 


Hy 2i er trophy  of  the  Intra-vaginal  Portion  of  tit e  Cervix. 

Etiology  and  Pathological  Anatomy.— I  shall  not  dwell  upon  ac- 
quired hypertrophy,  following  endometritis,  having  already  fully  de- 


Fig.  304. — Hypertrophy  op  the  Intra- Vaginal, 
■with  Elongation  of  the  Supra- Vaginal  Portion 
of  the  Cervix. 


Fig.  305. — Hypertrophy  of  the  Intra- 
Vaginal   Cervix  with  a  Deep  Bilateral 

Laceration. 


scribed  it  (p.  147).  I  would  simply  recall  the  fact  that  there  are  two 
varieties:  Follicular  hypertrophy,  which  especially  affects  the  mucous 
membrane,  which  is  filled  with  newly  formed  glands  that  have  under- 
gone cystic  degeneration;  and  sclero-cystic  hypertrophy,  where  the 
substance  of  the  cervix  is  distended  by  the  production  of  connective 
tissue  and  small  cysts  or  glands  of  Naboth. 

The  first  of  these  varieties  is  fungoid  and  soft  to  the  touch;  the 
second  nodulated  (tubereuse)  and  firm.  They  both  often  give  the 
cervix  the  appearance  of  a  club  or  of  a  bell-clapper  (Figs.  304  and  305.) 
Yery  different  in  form  and  structure  are  the  congenital  and  develop- 


544  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

mental  hypertrophies  which  appear  at  puberty  and  subsequently 
progress  more  or  less.  In  this  case  the  change  of  size  is  not  due  to 
inflammation.  The  whole  structure  of  the  uterus  seems  to  undergo 
hyperplasia  simultaneously,  without  deviation  from  the  normal  type; 
the  mucous  membrane  is  in  a  healthy  condition.  The  cervix  is  elong- 
ated, conoid  or  cylindrical  in  shape,  sometimes  like  a  tapir's  snout 
because  of  the  prominence  of  the  anterior  lip.a8  It  may  fill  the  vagina 
and  project  from  the  vulva,  leading  the  patient  to  suppose  that  there 
is  uterine  prolapse.  Stenosis  of  the  external  os  frequently  accom- 
panies this  affection,  as  I  have  already  stated  (Fig.  297). 

Symptoms  and  Diagnosis. — Dysmenorrhea  often  precedes  the 
appearance  of  the  cervix  at  the  vulva ;  in  young  girls  this  is  what 
usually  first  calls  attention  to  the  affection.  Married  women  suffer 
from  dyspareunia.  If  the  hypertrophy  is  not  very  marked,  the  male 
organ  pushes  it  to  the  front,  and  forms  a  species  of  false  vaginal  pas- 
sage by  depressing  the  posterior  cul-de-sac,  which  is  found  to  be  of 
increased  depth.  Pain,  leucorrhosa,  and  metrorrhagia  complete  the 
group  of  uterine  symptoms.  The  vaginal  touch  and  use  of  the  specu- 
lum will  reveal  the  nature  of  the  tumor ;  the  location  of  the  fundus  in 
its  normal  position  will  prevent  a  diagnosis  of  prolapsus  or  inversion ; 
the  connection  of  the  cervix  with  the  body  of  the  uterus,  and  the 
perception  of  the  external  orifice,  will  exclude  a  polypus.  Careful 
bimanual  palpation,  and  the  use  of  the  sound,  will  show  whether  there 
be  also  any  hypertrophy  of  the  supra-vaginal  portion  of  the  cervix. 

Prognosis  and  Treatment. — There  is  no  tendency  to  retrogression. 
Operative  procedures  alone  will  remove  this  source  of  continual  pain 
and  discomfort. 

Biconical  amputation  of  the  cervix  is  the  best  of  all  operations 
(p.  207).  If  hemorrhage  be  feared,  or  if  the  operator  be  not  sufficiently 
experienced  to  perform  the  operation  rapidly,  temporary  hsemostasis 
may  be  secured  by  tying  an  elastic  cord  above  a  strong  needle  which 
is  thrust  through  the  cervix  just  below  the  vaginal  attachment  and 
which  will  prevent  the  cord  from  slipping.  This  manoeuvre  is  ren- 
dered very  easy  of  accomplishment  by  the  use  of  my  elastic-ligature 
carrier. 

After  amputation  of  the  intra-vaginal  portion  of  the  cervix,  the 
supra-vaginal  portion,  if  hypertrophied,  may  undergo  a  retrogressive 
process  and  become  normal  in  size. 


MALFORMATIONS   OF   THE   CERVIX.  545 


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1885,  p.  21G.     Breisky:  Krankh.  der  Vagina,  in  Deutsche  Chirurgie,  Lief.  60,  1880. 

2.  G.  Lowe:  Case  of  Atresia  of  the  Uterine  Cervical  Canal;  Distention  of  the 
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6.  Beck:  Amer.  Jour,  of  Obstet.,  1874,  p.  353. 

7.  J.  C.  Smith:  Accidents  from  the  Use  of  Laminaria  Tents.  Amer.  Jour,  of 
Obstet.,  1888,  p.  694.     C.  C.  Lee:  Ibid.,  p.  498. 

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des  Uterus.     Zeitschr.  f.  Geb.  und  Gyn.,  1887,  Bd.  xiv.,  p.  259. 

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14.  Le  Blond:  Annales  de  Gyn^cologie,  1878.  Henry  Fry:  The  Relative  Merits 
of  Electrolysis  and  Rapid  Dilatation  in  the  Treatment  of  Sterility  and  Dysmenor- 
rhea.    Amer.  Jour,  of  Obst.,  xxi.,  p.  40. 

15.  Puech :  Ann.  de  Gyn.,  1874. 

16.  Staueh:  Zur  Kastration  wegen  Funktioniren  der  Ovarien  bei  rudimentarer 
Entwickelung  der  Mtlller'schen  Gange.  Zeitschr.  f.  Geb.  und  Gyn.,  1888,  Bd.  xv., 
p.  138.   ■ 

17.  Wilhelm  Thorn:  Beitrage  zur  Lehre  von  der  Atrophia  Uteri.  Zeitschr. 
f.  Geb.  und  Gyn.,  1889,  Bd.  xvi.,  Heft  1,  p.  57. 

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Gyn.,  Bd.  vii.,  p.  305. 

20.  Gottschalk:  Ein  Fall  hochgradiger  GalactorrhOe,  complizirt  mit  Atrophia 
Uteri  acquisita.  Heilung  durch  Skarifikation  der  Vaginalportion.  Deutsche  med. 
Zeitung,  1887,  viii.,  p.  913. 

21.  Hofmeier:  Berlin,  klin.  Wochenschr.,  1883,  No.  42.  Cohn:  Zeitschr.  f.  Geb. 
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1886,  p.  171.     A.  Nebel :  Kasuistischer  Beitrag  zur  Atrophie  der  weibl.  Genitalien 
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35 


546  CLINICAL   AND    OPERATIVE   GYNECOLOGY. 

22.  Levinstein :  Friihzeitige  Atrophie  des  gesainmten  Gfenitalapparates  in 
einem  Fall  von  Horphiuin-Missbrauch.  Centr.  fur  Cfyn.,  1887,  Nos.  40  and  52,  pp. 
633  and  841. 

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25.  Kelly:  Removal  of  Ovaries  and  Tubes  for  Subinvolution  and  Chronic  Me- 
tritis.    Amer.  Jour,  of  Obstetr.,  1887,  vol.  xx.,  p.  180. 

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1887. 


CHAPTER  XXII. 

DISORDERS   OF   MENSTRUATION. 

Precocious  and  Protracted  Menstruation. 

In  our  temperate  climate,  menstruation  usually  begins  in  the  fif- 
teenth year,  and  ends  in  the  forty-seventh,  giving  a'  menstrual  life  of 
about  thirty -two  years.  Those  who  menstruate  early  usually  con- 
tinue to  do  so  longer  than  usual.1 

Puberty  occasionally  occurs  at  a  very  early  age.  The  pubes  be- 
come covered  with  hair,  the  breasts  and  external  genitals  undergo 
rapid  development,  and  the  menses  finally  appear  and  either  continue 
with  great  regularity  or  cease  in  a  few  years.2  Campbell 3  has  recorded 
an  excessive  development  of  the  generative  organs  ia  a  child  of  four 
years,  who  had  regularly  menstruated  every  three  weeks  since  birth, 
Prochownick 4  had  the  opportunity  of  performing  an  autopsy  upon  a 
little  girl  of  three  years  who  had  begun  to  menstruate  at  one  year, 
and  found  upon  the  ovaries  all  the  signs  of  both  old  and  recent  ovu- 
lation. Young  girls  have  become  pregnant  at  the  incredibly  early  age 
of  eight,5  ten,6  eleven,7  and  twelve 8  years.  These  cases  of  precocious 
puberty  in  the  female  have  their  analogues  in  the  male.9 

A  report  of  protracted  menstruation  is  to  be  received  with  some 
reservation.  Women  not  far  from  the  menopause  are  apt  to  consider 
any  intermittent  or  irregular  hemorrhage  as  a  continuation  of  the 
menses,  especially  if  the  interval  between  them  and  the  last  period  has 
not  been  long. 

The  flow,  however,  may  be  caused  by  some  uterine  affection  whose 
existence  had  not  been  suspected,  as 10  endometritis,  mucous  polypi, 
fibromata,  and  esx^ecially  cancer.  It  is  true,  however,  that  some  indis- 
putably authentic  cases  have  been  reported  of  menstruation  lasting 
until  the  fifty-sixth  or  fifty-seventh  year.11 

Amenorrhea, 

By  amenorrhoea  we  mean  the  absence  of  menstruation,  and  not 
simply  the  lack  of  a  periodical  discharge  through  the  genital  tract. 
Menstruation  may  in  fact  exist,  but  in  a  latent  form,  as  in  the  case  of 


548  CLINICAL    AND   OPERATIVE   GYNAECOLOGY. 

retention  of  the  menstrual  flow  from  atresia,  etc.  We  must  carefully 
distinguish  between  these  two  classes  of  cases.  In  the  second,  the 
amenorrhcea  which  might  appropriately  be  called  obstructive,12  is 
merely  a  secondary  symptom ;  it  is  considered  in  the  chapter  upon 
Malformations  of  the  Genital  Organs. 

Primary  or  permanent  amenorrhcea  is  the  term  used  where  men- 
struation has  never  occurred;  it  has  also  been  called  emansio  men- 
sium.  The  amenorrhcea  which  is  called  transitory  or  secondary,  or 
accidental,  has  been  called  suppressio  mensium. 

Pathology— Etiology. — The  female  organism  between  puberty  and 
the  menopause  may  be  said  to  simultaneously  live  two  lives — that  of 
the  individual,  and  that  of  the  species ;  that  of  the  organs  in  general, 
and  that  of  the  generative  apparatus  in  particular.  This  dual  exist- 
ence, whose  physiological  and  psychological  effects  are  so  important, 
may  be  interrupted  by  the  influence  of  sickness,  as  it  is  by  that  of  age. 
Amenorrhcea  is  simply  the  absence  or  suspension  of  sexual  life,  pro- 
duced either  by  organic  impotence  or  by  a  profound  disturbance  of 
the  general  nutrition  of  the  individual.  We  must  look  at  the  matter 
from  this  point  of  view  in  order  to  fully  understand  the  unexpected 
and  excessive  disorders  caused  by  the  disturbance  of  this  equilibrium. 
The  sexual  apparatus  is  not,  so  to  speak,  an  accessory  wheel  in  the 
female  mechanism:  it  is,  on  the  contrary,  the  chief  wheel,  and  it  is  to 
secure  its  proper  action  that  constant  economies  and  reserves  are  made 
by  nature.  The  whole  economy  of  nutritive  receipts  and  expendi- 
tures bears  directly  upon  the  fact  that  a  woman  is,  according  to  na- 
ture's plan,  liable  at  any  time  to  conception.  The  Hindoos,  not  with- 
out some  show  of  reason,  consider  all  menstruation  which  has  not 
been  preceded  by  intercourse  to  be  infanticide ;  hence  young  girls  are 
married  just  before  puberty,  to  prevent  their  committing  the  crime 
even  once.  We  might  say,  with  paradoxical  conciseness,  that  a  wo- 
man's normal  condition  is  pregnancy  or  lactation.  During  these 
periods  menstruation  ceases;  it  returns  only  when  the  excess  of  nutri- 
tive material  is  no  longer  required  for  these  purposes.  Menstruation 
may  then  be  considered  a  safety-valve ;  its  absence  indicates  a  lower- 
ing of  nutrition,  when  it  is  not  the  normal  result  of  the  utilization  of 
the  nutritive  materials  for  the  reproduction  of  the  species. 

There  are  no  well-authenticated 13  exceptions  to  the  general  rule 
that  menstruation  is  suspended  during  pregnancy ;  there  are  many  ex- 
ceptions, however,  for  the  period  of  lactation,  but  the  milk  is  usually 
more  or  less  altered  in  quality  during  the  menstrual  flow.14 


DISORDERS   OF   MENSTRUATION.  549 

The  conditions  necessary  to  a  normal  and  regular  menstruation 
may  be  enumerated  as  follows : 

a.  Integrity  of  the  genital  apparatus. 

I).  Normal  condition  of  the  blood. 

c.  Normal  state  of  the  nervous  system. 

Any  disturbing  influence  originating  in  one  of  these  systems  may 
prevent  the  maturing  of  the  ovum,  or  disturb  ovulation,  or,  by  an 
inhibitory  influence  upon  the  sympathetic  or  vaso-motor  nerves,  in- 
terfere with  the  intense  congestion  which  is  the  necessary  precursor 
of  the  menstrual  flow.  Anything  impairing  the  integrity  of  the 
ovaries— cysts,  sclerosis,  periovaritis— acts  directly  upon  the  starting- 
point  of  the  reflex  action,  and  at  a  sufficiently  advanced  state  may 
abolish  it  entirely.  It  is,  however,  more  usual  for  these  injurious 
agents,  which  have  not  completely  destroyed  the  organ,  to  play  the 
opposite  part  of  excitants,  and  produce  menorrhagia  with  dysmenor- 
rhea, instead  of  amenorrhcea. 

Does  removal  of  both  ovaries  absolutely  cause  a  cessation  of  men- 
struation? This  question,  the  answer  to  which  at  one  time  seemed 
positive,  has  of  late  been  asked  by  surgeons  after  a  vast  number  of 
experiments  whose  results  were  contradictory.  In  considering  the 
matter  one  great  distinction  must  be  observed.  The  same  importance 
should  not  be  given  to  cases  where  cystic  or  papillary  tumors  have 
been  removed,  as  to  those  where  ovariotomy  is  performed  for  slight 
changes,  as  sclero-cystic  degeneration,  which  have  modified  but  little 
the  size  and  connections  of  the  organ,  or  even  where  it  is  performed  upon 
perfectly  healthy  ovaries  (Battey's  operation).  Cases  of  the  first  class 
should  be  carefully  inquired  into,  for  in  the  case  of  a  large  tumor  it  is 
often  impossible  to  affirm  positively  that  a  small  fragment  of  ovarian 
tissue  has  not  been  left  in  the  pedicle,  and  that  would  in  itself  be 
quite  sufficient  to  allow  of  the  continuation  of  menstruation.  There 
remain  a  large  number  of  well-authenticated  cases  belonging  to  the 
second  class,  where,  in  spite  of  a  double  ovariotomy,  menstruation 
continues  with  more  or  less  regularity.15  But  if  the  cases  are  atten- 
tively followed  for  any  length  of  time,  it  will  be  found  that  this 
posthumous  menstruation,  so  to  speak,  invariably  ceases  after  a  few 
months.  It  is  quite  unnecessary  to  suppose  the  existence  of  a  sup- 
plementary  ovary:  the  well-known  law  of  the  persistence  of  habit 
will  sufficiently  account  for  the  phenomenon.  The  nervous  system 
automatically  reproduces  congestion  of  the  generative  apparatus. 
The  process  seems  to  continue  from  its  own  momentum  for  a  while, 


550  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

and  finally  becomes  slowed  and  ceases  because  of  the  lack  of  further 
impulse.  Another  factor  which  may  cause  the  temporary  prolonga- 
tion of  the  menstrual  molimen  is  the  existence  of  any  impairment 
of  the  mucous  membrane  or  substance  of  the  uterus,  such  as  always 
remains  after  the  performance  of  ovariotomy  for  a  fibroid  tumor,  and 
is  apt  to  be  present  after  removal  of  the  appendages  for  obstinate  cases 
of  oophorosalpingitis.  Therefore  I  consider  it  essential  in  such  cases 
to  follow  the  principal  operation  by  a  complementary  curetting  of  the 
uterus.16  Czempin 17  attaches  some  value,  as  a  factor  in  the  process,  to 
the  passive  congestion  due  to  the  compression  of  veins  by  the  cicatri- 
cial tissue  resulting  from  the  operation.  The  amenorrhoea  following 
ovariotomy  is  accompanied  by  certain  general  physical  changes:  an 
increase  of  embonpoint,  atrophy  of  the  mammary  glands,  and  some- 
times a  marked  change  in  the  disposition  which  often  becomes  more 
placid.18  Removal  of  the  Fallopian  tubes  alone  does  not  seem  to  in- 
fluence menstruation,  providing  that  the  ovaries  be  healthy,19  which 
fact  upsets  Lawson  Tait's  theory  of  the  paramount  influence  of  these 
organs  upon  this  function. 

Primary  amenorrhoea  may  be  due  to  malnutrition,  which  causes 
a  delay  in  general  development.  Over-stimulation  of  the  intellectual 
faculties,  with  too  little  physical  exercise,  a  condition  of  things  found 
in  certain  convents  and  schools,  may  cause  amenorrhoea  as  well  as 
chlorosis.  Weakly  young  girls  with  a  strumous  taint  are  especially 
predisposed  to  it.  On  the  other  hand,  the  change  of  regimen,  the 
rapid  substitution  of  an  abundant  and  stimulating  diet,  and  the  ab- 
sence of  their  accustomed  exercise  in  the  open  air  in  young  girls  who 
are  transplanted  from  a  country  to  a  city  home,  while  causing  sudden 
plethora,  often  causes  a  delay  in  the  appearance  of  the  menses. 

Secondary  amenorrhoea  may  follow  impoverishment  of  the  blood, 
and  the  profound  debility  resulting  from  a  chronic  disease  or  follow- 
ing an  acute  illness.  Anaemia,  chlorosis,  Bright's  disease,  diabetes,20 
alcoholism,21  morphinism,22  cancerous  or  malarial  cachexia,  pulmonary 
tuberculosis,  convalescence  from  fevers,  are  all  potent  in  producing 
amenorrhoea;  acute  or  chronic  surgical  affections  may  act  in  the 
same  way.  These  facts,  which  have  recently  elicited  much  study, 
were  observed  and  commented  on  by  Dupuytren.23  It  is  to  the  pro- 
found anaBmia  accompanying  the  onset  of  the  diathesis  to  which  we 
must  attribute  the  amenorrhoea  of  syphilitic  women  upon  which  A. 
Fournier 24  lays  such  stress,  and  that  of  young  women  who  are  the 
victims  of  obesity,25  often  a  most  debilitating  dystrophia.    The  condi- 


DISORDERS    OF   MENSTRUATION.  551 

tion  of  the  nervous  system  has  a  decided  influence  upon  the  production 
of  amenorrhcea.  Fright  may  cause  a  temporary  suspension  of  the 
menses.  On  the  other  hand,  there  are  cases  on  record  where  amenor- 
rhea has  been  cured  by  some  sudden  emotion.26  The  amenorrhcea  of 
prisoners  and  of  insane  women  confined  to  asylums  is  due  as  much 
to  the  mental  depression  as  to  the  anremia  consequent  upon  seclusion. 
Chlorosis,  which  causes  amenorrhcea,  seems  to  be  a  disease  of  the 
nervous  system.  Absence  of  menstruation  is  often  noted  in  the 
hysterical.  Sudden  chilling,  which  is  often  given  as  a  cause  of 
amenorrhcea,  probably  acts  through  the  vaso-motor  tract.  The  emo- 
tional amenorrhcea  of  the  newly  married,  or  of  women  who  are  very 
desirous  of  having  children,  is  probably  to  be  referred  to  the  inhibitory 
power  of  the  nervous  system;  its  occurrence  simultaneously  with 
tympanites  has  often  been  the  cause  of  bitter  disappointment.  Anxiety 
may  induce  amenorrhcea  in  women  who,  because  of  the  irregularity  of 
their  lives  or  from  some  other  reason,  dread  pregnancy  (Raciborski).27 
1  have  seen  several  instances  of  this.  The  last  two  forms  may  be  due 
in  part  to  auto-suggestion.23  Atrophy  of  the  uterus  from  superinyo- 
lutiou  after  repeated  pregnancies,  prolonged  lactation,  etc.,  causes 
amenorrhcea.29 

Symptoms. — The  chief  sign  is  of  course  the  absence  of  the  periodi- 
cal flow  through  the  genital  tract.  But  we  should  not  overlook  the 
accompanying  nervous  symptoms  which  may  be  very  serious,  and 
which  occur  in  the  form  of  chlorosis  or  of  hysteria.     Sensory  disturb- 


31 


ances,  such  as  impairment  of  vision 30  and  of  hearing,  and  paraplegia,3 
seem  to  depend  as  much  upon  amemia  as  upon  hysteria. 

Amenorrhcea  in  some  patients  is  accompanied  by  the  cutaneous 
eruptions  which  in  other  women  occur  during  menstruation — acne, 
eczema,  herpes,  urticaria,  pemphigus,  erysipelas.32  Hyperidrosis  and 
a  swelling  of  the  hands  and  feet  have  been  known  to  occur,  doubtless 
from  angio-neuroses.33 

These  curious  facts  lead  naturally  to  the  study  of  vicarious  men- 
struation,34 as  they  demonstrate  the  harmony  existing  between  differ- 
ent parts  of  the  organism,  and  the  possibilities  of  an  interchange  of 
function  between  the  external  integument  and  the  uterine  mucous 
membrane.  Science  has  on  record  some  curious  examples  of  what 
may  be  called  substituted  secretions.  Jones35  reports  the  case  of  a 
young  woman  in  whom  menstruation  was  checked  apparently  from 
sudden  chilling,  who  then  suffered  from  amenorrhcea,  and  for  five 
years  had,  instead  of  the  menstrual  flow,  an  abundant  flow  of  milk 


552  CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 

from  the  breasts,  which  lasted  thirty-six  hours.  In  another  woman, 
who  had  borne  several  children,  the  catamenial  period  was  charac- 
terized by  a  profuse  diarrhoea  for  three  days,  accompanied  by  leucor- 
rhcea,  with  a  subsequent  scanty  discharge  of  blood.  He  also  mentions 
a  case  in  which  periodical  leucorrhoea  replaced  the  normal  flow. 

Vicarious  or  ectopic 36  menstruation  is  met  with  in  the  most  ex- 
traordinary and  unexpected  forms.37  The  discharge  most  frequently 
occurs  from  the  bronchial  or  pulmonary38  mucous  membrane,  the 
patient  having  hsemoptyses,  which  may  lead  to  a  diagnosis  of  incip- 
ient phthisis.  Hsematemesis  has  been  observed,  and  epistaxis,  rectal 
hemorrhages,39  especially  in  plethoric  patients  with  hemorrhoids — and 
otorrhagia40 — either  where  a  pre-existing  purulent  otorrhcea  had 
made  this  portion  of  the  frame  a  locus  minoris  resistentiae,  or  when 
the  tympanum  was  intact.  Of  rarer  occurrence  are  cutaneous  hemor- 
rhages in  the  form  of  ecchymoses  and  petechial  spots,  or  a  flow  of 
blood  from  the  surface  of  some  one  special  point  where  the  skin  is 
unbroken 41  or  from  the  surface  of  an  ulcer.  In  the  hospital  of  Saint- 
Louis  I  saw  a  patient,  suffering  from  lupus  of  the  face,  who  had  an 
abundant  flow  of  blood  in  this  situation  at  each  menstrual  period. 

Treatment— -It  is  a  mistake  to  suppose  that  amenorrhcea  calls  for 
special  medication  supposed  to  have  an  elective  action  upon  the 
uterine  mucous  membrane.  Emmenagogues— rue,  savine,  saffron,42 
apiol43— are  of  use  only  in  a  few  limited  cases,  where  some  decided 
influence  (as  cold,  or  violent  emotion)  has  caused  a  suspension  of  the 
menses,  and  should  be  administered  with  moderation  at  the  time  the 
flow  is  expected.  The  same  may  be  said  of  hot  baths  (104°  to  113°  F.). 
Drastic  and  saline 44  purgatives  may  then  be  given  for  the  purpose  of 
causing  a  certain  amount  of  pelvic  congestion.  Of  late,  permanganate 
of  potash 45  has  been  recommended  as  almost  a  specMic.  As  a  rule,  we 
should  try  to  reach  the  cause  of  the  disease,  and,  amenorrhcea  depend- 
ing usually  upon  poverty  of  the  blood  or  upon  some  nervous  trouble, 
we  must  have  recourse  to  nutrition,  tonics,  and  alteratives,  especially 
iron  or  manganese46  or  hydrotherapy.  I  depend  much  more  upon 
this  general  treatment  than  upon  such  measures  as  scarification  of  the 
cervix,  application  of  a  galvanic  pessary,  etc.  Electricity  (faradic) 
may  give  good  results,  and  should  not  be  omitted.  Bigelow 47  recom- 
mends static  electricity  (franklinization)  for  the  amenorrhcea  of 
chloro-ansemic  girls,  as  a  general  tonic.  In  the  intermittent  form  of 
amenorrhcea  found  in  plethoric  patients,  we  may  use  the  continuous 
current,  placing  the  positive  pole  in  the  uterine  cavity.     In  the  un- 


DISORDERS    OF   MENSTRUATION.  553 

married,  one  electrode  may  be  placed  upon  the  lumbar  region,  and 
the  other  externally  over  the  site  of  the  uterus ;  in  the  married  it  is 
better  to  place  one  electrode  in  the  uterus  and  the  other  on  the  hypo- 
gastrium.  Bigelow  also  advocates  general  electricity  for  amenorrhea, 
one  electrode  being  placed  on  the  back  of  the  neck,  and  the  other  in 
a  foot-bath  of  salt  water.  He  finds  this  particularly  useful  in  the  case 
of  young  girls  who  are  irritable,  nervous,  and  chlorotic.  The  treat- 
ment should  be  started  a  few  days  before  the  period  is  due,  and  be 
taken  daily  until  that  time.  Physical  exercise,  walks  in  the  open  air, 
gymnastics,  sea  or  mountain  air,  amusements,  and  distraction  from  all 
anxiety  are  to  be  prescribed  as  well. 

Where  amenorrhcea  occurs  in  young  women  who  are  obese  or 
threatened  with  obesity,  I  have  often  caused  a  return  of  the  menses 
by  treating  the  obesity,  prescribing  a  diet  free  from  fluids  and  starchy 
foods,  exercise,  thermal  baths  (Brides,  Salies  de  Beam),  and  finally  by 
stimulation  of  the  uterine  mucous  membrane  by  curetting,  followed 
by  iodine  injections  at  the  date  that  menstruation  should  occur. 

In  women  in  whom  amenorrhcea  follows  an  ovariotomy,  it  is  not 
unusual  in  the  first  few-  months  to  observe  periodical  disturbances 
[practically  identical  with  those  which  occur  at  the  physiological  meno- 
pause]—lumbar  pains,  flashes  of  heat,  vertigo,  and  a  special  form  of 
irritability ;  in  short,  a  molimen  which  is  all  the  more  painful  because 
it  is  longer  in  duration  than  the  normal  crisis.  In  these  cases  I  have 
obtained  good  results  from  scarifying  the  cervix  and  obtaining  a  slight 
local  bleeding  every  month  at  the  time  of  the  disturbance.  I  also  use 
saline  purgatives.  One  of  my  patients  came  to  me  regularly  for  a 
year  to  obtain  the  relief  afforded  by  this  treatment.  In  the  end,  these 
phenomena  disappear  spontaneously. 

Menorrhagia. 

A  notable  increase  in  the  menstrual  flow  constitutes  menorrhagia; 
a  discharge  of  blood  in  the  interval  between  the  periods  is  called 
metrorrhagia. 

Symptoms. — A  profuse  and  prolonged  flow,  the  formation  of  clots, 
and  general  debility  are  the  symptoms  of  what  is  not  in  itself  a 
disease,  but  a  symptom  of  several  diseases. 

Etiology— Pathology. — The  cause  may  be  general  or  local. 

1.  General  causes  act  by  altering  the  composition  of  the  blood;  to 
this  class  belong  the  various  dyscrasise,  haemophilia,  purpura,  scorbu- 
tus, severe  icterus,  phosphorus  poisoning,  Bright's  disease,  AVeiihofs 


554  CLINICAL   AND    OPERATIVE    GYNAECOLOGY. 

disease,  obesity,  and  cachexia.     Sometimes  in  these  cases  amenorrhoea 
alternates  with  menorrliagia.     Finally,  uterine  epistaxis  (Gubler)  may 
mark  the  onset  of  fevers. 
2.  The  local  causes  are : 

A.  Reflex  stimulus  from  the  genital  organs  (especially  the  ap- 
pendages), without  any  existing  lesion,  simply  from  nervous  derange- 
ment, as  at  puberty,  first  intercourse,  or  the  menopause.  We  must 
include  in  this  class  the  metrorrhagia  caused  by  lactation,48  which  is 
no  doubt  due  to  reflex  stimulation  from  the  mammary  glands. 

B.  Nearly  every  disease  of  the  uterus  and  its  appendages ;  endo- 
metritis, fibromata,  cancer,  ovarian  tumors,49  especially  those  situated 
near  the  uterus,  as  intraligamentous  cysts,  and  affections  of  the  Fallo- 
pian tubes.  As  in  this  chapter  I  do  not  pretend  to  do  more  than 
outline  the  diseases  causing  menorrliagia,  I  shall  content  myself  with 
this  enumeration,  without  going  into  descriptive  details ;  each  affec- 
tion will  be  found  described  at  length  under  its  appropriate  heading. 

Treatment. — Unless  this  symptom  threaten  serious  danger,  it  need 
not  be  treated  by  itself,  but  the  cause  should  always  be  sought  for. 
A  mere  mention  of  the  haemostatic  measures  at  our  command  will 
suffice.  The  local  means  are:  prolonged  irrigations  of  very  hot  water 
(110°  to  120°  F.)  and  tamponade  of  the  vagina.  Emmet  was  the  first 
to  use  temporary  suture  of  the  cervix,  which  may  be  done  if  all  other 
measures  fail.50  I  have  seen  Martin  ligate  en  masse  the  inferior 
branches  of  the  uterine  artery  through  the  vaginal  culs-de-sac  (p.  117), 
with  successful  result. 

General  measures  are  to  be  simultaneously  employed;  rest  in  bed, 
with  slight  elevation  of  the  pelvis;  opium  in  the  form  of  laudanum; 
rectal  injections;  ergot,51  by  the  stomach  and  hypodermatically.  Gal- 
lard  places  a  high  value  upon  the  infusion  of  digitalis  leaves 52  given 
to  the  point  of  toxic  effect. 

[In  many  cases  fluid  extract  of  hydrastis  given  in  half-drachm 
doses  every  four  hours  during  the  time  of  the  flow,  and  in  twenty- 
drop  doses  before  meals  in  the  intervals,  is  very  efficient.  Oil  of 
erigeron  in  5-minim  capsules  every  three  hours  is  also  effective. 
Goodell  speaks  confidently  of  the  value  of  the  following: 

5  Extr.  ergotae  fl., m  x.        gm.  .65 

Ammonii  chloridi,      .        .        .        .        gr.  x.  "     .65 

Sodii  bromidi, gr.  v.         "     .31 

Mi  see  et  signa:  For  one  dose,  to  be  taken  in  half  a  tumbler  of 
water;  may  repeat  every  two  hours. 


DISORDERS    OF   MENSTRUATION.  555 

All  of  these  measures  are  only  palliative  and  of  very  slight  im- 
portance compared  with  the  treatment  of  the  causal  factor  of  the 
bleeding.] 

If  menorrhagia  becomes  threateningly  severe,  would  it  be  justifi- 
able, in  the  absence  of  an  exact  diagnosis,  to  perform  a  radical  opera- 
tion? Vaginal  hysterectomy  has  in  some  cases  seemed  justifiable, 
for  a  hemorrhagic  endometritis  which  resisted  all  other  treatment 
(p.  212).  Some  operators  have  performed  ovariotomy,  which  is  a 
less  serious  operation  and  quite  as  efficacious.53 

Olshausen  mentions  the  case  of  a  woman  of  thirty-nine  years  who 
suffered  from  such  severe  menorrhagia,  with  no  discoverable  cause, 
that  he  performed  an  ovariotomy,  with  the  greatest  success.  Yet  we 
should  beware  of  creating  a  therapeutic  law  out  of  such  exceptional 
cases,  and  Walton 54  has  quite  justly  protested  against  the  over-zeal 
for  operation  of  some  surgeons. 

Dysmenorrhoza  and  Menstrual  Disorders  of  Nervous 

Origin. 

At  the  menstrual  period,  women  normally  feel  unwell,  as  they  ex- 
press it;  that  is  to  say,  they  experience  a  general  malaise,  a  few  vague 
pains  in  the  loins,  and  a  certain  irritability  of  temper.  These  symp- 
toms are,  however,  not  at  all  pronounced.  If  menstruation  becomes 
painful  it  is  called  dysmenorrhea,  which  has  been  divided  and  sub- 
divided into:  1st,  Neuralgic  or  sympathetic  dysmenorrhoea ;  2d,  con- 
gestive or  inflammatory;  3d,  mechanical  or  obstructive;  4th,  mem- 
branous; 5th,  ovarian.  This  classification  may  be  simplified  by 
grouping  the  pains  under  two  heads,  according  to  whether  they  occur 
during  the  ovarian-tubal  period  (ripening  of  the  follicle")  or  during 
the  uterine  period  (expulsion  of  the  menstrual  blood). 

Dysmenorrhea  of  Ovarian  Origin. 

This  may  be  the  result  of  incomplete  development  of  the  genital 
organs,  the  ovaries  and  uterus  being  of  the  pubescent  variety ;  or  this 
may  be  the  case  with  the  uterus  alone,  the  ovaries  having  attained  an 
adult  development.  A  want  of  regularity  in  the  function  of  menstru- 
ation will  of  course  result  from  the  difficulty  of  ovulation,  or  from 
the  disproportion  existing  between  the  intensity  of  the  congestive 
phenomena  in  the  ovaries  and  that  in  the  uterus ;  which  produces  an 
exaggerated  erethism  in  the  ovaries,  with  consequent  suffering. 


556  CLINICAL   AND    OPEEATIYE   GYNAECOLOGY. 

Disease  of  the  appendages  is  another  frequent  cause.  I  do  not 
refer  to  acute  inflammations  only,  or  to  serious  affections,  as  salpingi- 
tis, hydro-,  hremato-  and  pyo-salpinx.  But  the  remains  of  old  lesions 
(often  limited  in  extent),  adhesions,  false  membranes  compressing  the 
uterine  appendages  or  binding  them  down  in  an  abnormal  position 
(producing  sclerosis  of  the  ovaries  and  obstruction  of  the  tubes),  are 
the  frequent  but  unrecognized  cause  of  intense  pain  at  the  menstrual 
period.  Tubo-ovarian  varicocele  (Richet),  or  varicose  dilatation  of 
the  pampiniform  plexus  and  the  veins  of  the  broad  ligament,  seems 
to  have  some  causative  influence ;  a  varicose  condition  is,  moreover, 
usually  accompanied  by  chronic  ovaritis  and  ovarian  atrophy,  just  as, 
in  the  male,  it  may  be  followed  by  atrophy  of  the  testicle. 

Dysmenorrhea  of  Uterine  Origin. 

The  principal  factor  is  the  existence  of  any  mechanical  obstacle  to 
the  expulsion  of  the  blood;  stenosis  of  the  cervix  with  or  without 
hypertrophy ;  displacements  of  the  uterus,  especially  flexions ;  endo- 
metritis (causing  swelling  of  the  mucous  membrane,  and  salpingitis): 
the  various  forms  of  tumors,  fibroids,  mucous  polypi,  cancers,  etc. 
I  have  described,  under  the  head  of  acute  endometritis,  the  special 
form  which  is  accompanied  by  complete  desquamation  of  the  mucous 
membrane,  and  which  many  authorities  have  described  as  a  separate 
disease,  membranous  dysmenorrhcea. 

Can  we  recognize  a  dysmenorrhcea  due  to  the  rheumatic  or  gouty 
diathesis?  I  think  not,  and  that  we  are  only  justified  in" saying  that 
patients  suffering  from  these  complaints  are  liable  to  every  form  of 
neuralgia. 

Symptoms  and  Diagnosis. — The  pain  of  dysmenorrhcea  differs 
widely  according  to  its  origin.  At  the  onset  of  menstruation  the 
ovarian  pains  predominate ;  the  uterine  pains  are  the  most  pronounced 
when  the  flow  becomes  fully  established. 

Inter-menstrual  DysmenorrTioea  (Mittelschmerz,  of  the  German 
authorities)  is  erroneously  so  called.  The  name  has  been  applied  to 
spasmodic  pains  in  the  ovarian  region,  occurring  in  the  intervals  be- 
tween the  menses,  and  hypothetically  attributed  to  ovulation.55  These 
are  really  symptoms  of  inflammation  of  the  uterus  or  the  appendages. 

I  have  already  described 56  the  character  of  dysmenorrhceal  pain, 
and  shall  not  here  dwell  upon  it  at  length. 

As  a  rule,  the  pain  makes  its  appearance  with  the  flow,  and  is  es- 
pecially severe  on  the  first  two  days.     Sometimes,  even  when  there  is 


DISORDERS    OF   MENSTRUATION.  557 

no  mechanical  obstacle  and  no  narrowing  of  the  cervical  canal,  the 
blood  is  discharged  drop  by  drop  (like  the  urine  in  strangury),  a 
phenomenon  which  Aetius  called  stillicidinm  uteri.  Small  clots  indi- 
cate a  stagnation  of  blood  in  the  uterine  cavity,  and  their  expulsion 
may  cause  spasms  of  colicky  pain  so  intense  as  to  produce  hysterical 
attacks  and  even  syncope. 

The  menstrual  period  may  fcr  a  long  time  be  a  period  of  actual 
relief  to  the  patient,  and  then  become  exceedingly  painful;  this  is 
specially  noted  in  cases  where  salpingitis  passes  from  the  acute  to 
the  chronic  state. 

The  differential  diagnosis  consists  in  distinguishing  dysmenor- 
rhoea  from  lumbo-abdominal  neuralgia,  which  is  increased  at  the  men- 
strual period;  the  coexistence  of  neuralgia  in  other  localities,  and 
the  identification  of  Valleix's  painful  jjoints  will  facilitate  the  diagno- 
sis. To  determine  whether  the  pain  is  of  ovarian  or  uterine  origin,  a 
careful  study  of  local  conditions  will  be  necessary.  The  phenomena 
preceding  menstruation  will  assist  us  in  forming  an  opinion. 

This  question  of  diagnosis  occurs  in  regard  to  the  various  uterine 
diseases  of  which  I  have  spoken. 

I  would  call  especial  attention  to  the  dysmenorrhcea  and  the  grave 
reflex  phenomena  which  may  be  produced  by  prolapse  of  the  ovary. 
By  vaginal  or  rectal  touch  we  shall  be  able  to  find  a  tumor  in  the 
pouch  of  Douglas,  pressure  upon  which  causes  a  peculiar  and  char- 
acteristic nauseating  pain.  Two  accomx>anying  symptoms  are,  pain 
during  defecation  and  coition,  dyschezia  and  dyspareunia  of  the  Eng- 
lish books.57 

Battey.  and  many  other  gynaecologists  following  his  teachings,  es- 
pecially in  America,  attach  much  importance  to  the  coexistence  of 
menstrual  disorders,  amenorrhea  and  dysmenorrhcea,  with  grave 
nervous  disorders,  hysteria,  epilepsy,  mania ;  they  have  even  created  the 
terms  oophoralgia,  oophoro-epilepsy,  oophoro-mania.  Beyond  doubt, 
many  of  these  affections  are  of  reflex  origin,  and  proceed  from  unde- 
veloped or  diseased  ovaries.  But  an  exact  diagnosis  is  difficult  to 
reach,  and  the  surgeon  should  be  more  guarded  in  his  opinions  than 
many  have  been  on  the  other  side  of  the  Atlantic.  There  are  a  few 
clearly  defined  cases  Avhere  the  preponderating  influence  of  the  men- 
strual epoch  is  recognized  beyond  question,  and  the  congested  ovary 
is  the  cause  of  the  aura  of  epilepsy  for  instance ;  there  are  many  more 
where  the  menstrual  disorders  merely  coincide,  without  being  causa- 
tive. 


558  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

As  palliative  treatment  for  the  pain,  we  may  use  potassium  bro- 
mide, chloral,58  valerianate  of  ammonia,  asafcetida,59  musk,  tincture  of 
cannabis  indica,  belladonna,  and  hyoscyamus.60  Antipyrine 61  hypo- 
dermatically  injected  is  a  valuable  resource;  intense  spasms  of  pain 
may  be  relieved  by  the  careful  administration  of  a  few  whiffs  of  ether. 
Oxalate  of  cerium 62  has  been  extolled.  Wylie 63  praises  electricity ; 
he  inserts  the  iDositive  pole  in  the  cervix. 

Laudanum  and  valerian  douches  often  afford  relief  when  all  other 
remedies  fail.  General  treatment  will  attempt  to  reach  the  anaemic 
or  nervous  condition  of  the  patient. 

[Routh64in  an  excellent  resume  of  the  subject  writes:  "Success- 
ful treatment  depends  upon  finding  and  removing  the  cause.  As  a 
rule  it  is  irrational  to  mask  the  symptom  of  pain  by  giving  opiates, 
though  during  a  severe  paroxysm  it  may  be  necessary ;  but  even  then 
we  should  add  atropine,  belladonna,  or  hyoscyamus,  to  relax  muscular 
spasm,  to  avert  constipation,  and  to  enable  us  to  use  smaller  doses  of 
the  opiate.  The  main  objection  to  opium,  chloral,  or  alcohol  is  that 
their  repetition  tends  to  their  abuse.  Nitro-glycerin  and  amyl  nitrite 
are  excellent  for  spasmodic  cases.  The  bromides  are  indicated  in 
those1  cases  where  the  dysmenorrhoea  is  supposedly  ovarian.  Can- 
nabis indica  is  valuable  when  menorrhagia  coexists.  A  favorite  pre- 
scription, both  in  congestive  and  spasmodic  dysmenorrhoea  is : 

$  Tr.  cardamomi  comp.,         -  3  ss.  gm.    2. 

Spir.  chloroformi, 

Liq.  ammonii  acetat., 

Tr.  belladonna?,  . 

Aq.  cinnamomi,  .        q.s.  ad  % 

M.  S.  For  one  dose. 

I  have  found  the  tincture  of  Pulsatilla,  given  for  some  days  before 
the  period  in  five-drop  doses  three  times  daily,  quite  efficient  in  the 
neuralgic  form  common  in  young  women.  In  congestive  dysmenor- 
rhoea saline  laxatives,  hot  sitz-baths,  and  fifteen  to  twenty  grain  doses 
of  phenacetin  every  six  to  eight  hours  are  effectual.  For  obstructive 
dysmenorrhoea  thorough  dilatation  of  the  uterine  canal  gives  the  best 
results.     All  internal  medication  is  uncertain.] 

No  general  rule  can  be  given  about  curative  treatment,  which  will 
vary  according  to  the  cause  of  the  dysmenorrhoea.  The  initial  lesion, 
whether  it  be  in  the  uterus  or  the  appendages,  is  the  one  to  be  treated. 


m  xx. 

"      1.3 

3SS. 

"    15.5 

m  x. 

"      0.65 

!i. 

"    31. 

DISORDERS    OF   METTSTBTTATIOK.'  559' 

Where  there  is  doubt  about  the  existence  of  this  lesion,  or  where  the 
trouble  is  functional  and  its  origin  not  well  determined,  the  thera- 
peusis  is  difficult.  In  many  cases  where  the  trouble  is  due  to  a  delay 
in  the  perfect  development  of  the  internal  genital  organs,  with  or 
without  cervical  stenosis,  it  will  often  disappear  spontaneously  with 
age,  marriage,  and  conception.  In  some  cases,  however,  the  ovaries 
and  uterus  whose  functions  are  unequally  performed,  do  not  become 
restored  to  a  normal  condition;  in  other  cases,  acquired  lesions  (ad- 
hesions, displacements)  permanently  impair  the  functional  powers  of 
the  ovary.  The  periodical  pain  becomes  unbearable  and  the  general 
health  deteriorates.  Moreover,  it  has  been  supposed  that  grave  ner- 
vous disorders,  epilepsy  and  mania,  were  of  reflex  origin,  due  to 
the  dysmenorrhea ;  it  is  in  these  cases  that  removal  of  healthy 
ovaries  has  been  performed  in  order  to  stop  the  pain  by  abolishing 
the  function  which  caused  it.  The  special  indication  for  oophorec- 
tomy, castration,  or  normal  ovariotomy  (a  term  signifying  that  the 
ovary  is  of  normal  size),  was  first  pointed  out  by  Battey 65  in  America, 
then  by  Hegar 66  in  Germany,  and  Lawson  Tait 6T  in  England.  Ac- 
cording to  Battey,6S  whose  name  the  operation  bears,  the  surgeon,  be- 
fore performing  an  ovariotomy  in  such  cases,  should  ask  himself:  1st. 
Is  the  case  a  serious  one  ?  2d.  Is  it  curable  by  any  other  medical  or 
surgical  means  ?    3d.  Can  it  be  cured  by  the  menopause  ? 

The  last  question  is,  in  truth,  the  ail-important  one.  Ovarian  pain 
in  itself  is  not  enough  to  prove  that  the  ovary  is  the  starting-point 
of  the  trouble:  there  is  an  ovarian  congestion  accompanying  hysteria; 
moreover,  neuralgic  pains  of  central  origin  may  radiate  centrifugally. 
Sound  teeth  are  frequently  rendered  sensitive  by  neuralgia  of  the 
trigeminal;  no  one  would  dream  of  extracting  them.69  This  very 
arjpropriate  comparison  of  Olshausen  has  been  met  by  the  reply  that, 
normal  ovariotomy  being  a  benign  operation  and  the  pain  suffered  of 
an  excruciating  nature,  many  patients  would  be  willing  to  submit  to 
the  operation  for  the  uncertain  chance  of  a  cure.  It  would  at  least 
put  a  stop  to  the  exacerbation  of  pain  at  the  menstrual  period. 

Lawson  Tait  has  had  encouraging  results  with  ovariotomy  in  the 
cure  of  menstrual  epilepsy.  Yet  G.  Willers,  a  pupil  of  Hegar,  has 
proved  that  there  is  more  chance  of  cure  if  the  ovary  be  diseased  than 
if  it  be  healthy.  The  same  is  true  of  hysteria  and  hystero-epilepsy 
with  acute  exacerbation  at  the  menstrual  period. 

Ovariotomy  has  given  some  good  results70 — it  has  also  resulted  in 
many  failures.     Some  of  the  cures  are  quite  remarkable,  but  they  may 


560  CLINICAL   AND    OPEEATIVE   GYNAECOLOGY. 

be  only  temporary 71  in  their  effect,  and  often  no  cure  follows.  We 
must  also  ask  ourselves  whether  the  cures  may  not  oftentimes  be  due 
to  the  deep  psychical  impression  produced  by  the  operation— to  a 
species  of  suggestion,  in  short.  As  a  proof  of  this  being  possible,  we 
would  instance  the  good  effect  produced  in  a  few  cases  by  a  pretended 
ovariotomy.72  As  to  ovariotomy  for  mania  or  psychoses  apparently 
influenced  by  menstruation,  I  believe  that  it  should  be  prohibited. 
In  some  cases  of  this  kind  the  trouble  has  been  aggravated  instead 
of  cured  by  the  procedure.  It  is  difficult  to  appreciate  the  point  of 
view  of  those  surgeons  who  practise  ovariotomy  for  the  purpose  of 
producing  sterility  and  preventing  the  transmission  of  hereditary  in- 
sanity.73 I  have  as  yet  said  nothing  as  to  the  anatomical  condition  of  ■ 
the  ovaries.  In  spite  of  Hegar's  praiseworthy  efforts  to  restrict  ovari- 
otomy to  cases  where  lesions  of  the  ovary  can  be  demonstrated,  and 
to  give  this  operation  an  anatomical  basis,  even  when  it  is  performed 
for  nervous  conditions  only,  it  is  an  undoubted  fact  that  in  the  great 
majority  of  cases  such  positive  diagnosis  cannot  be  made.74 

Sclero-cystic  degeneration,  cirrhosis,  and  hyperplasia  of  the  stroma 
are  rarely  recognizable  by  bimanual  palpation ;  and  as  for  the  symp- 
toms produced  by  these  lesions,  they  differ  in  nowise  from  those  of 
purely  nervous  origin. 

It  seems  to  me  beyond  doubt  that  removal  of  even  healthy  ovaries 
has  often  modified  the  condition  of  the  nervous  system  so  as  to  cause 
a  disapjjearance  of  the  grave  reflex  disturbances  accompanying  men- 
struation.75 Consequently  the  operator  should  be  less  anxious  to  know 
whether  the  ovary  to  be  removed  presents  an  anatomical  lesion,  than 
to  know  whether  it  be  the  physiological  starting-point  of  the  trouble ; 
rational  symptoms  will  in  this  case  tell  him  more  than  physical  ex- 
amination. But  an  absolute  diagnosis  is  difficult  to  establish;  and 
unless  he  be  very  positive  as  to  the  cause,  a  conscientious  surgeon  will 
hesitate  to  perform  an  operation  which,  when  it  does  not  cure  the 
disease,  constitutes  a  mutilation  of  the  patient,  which,  from  a  social 
point  of  view,  is  more  serious  than  the  amputation  of  a  limb. 

Pean 76  prefers  vaginal  hysterectomy,  which  he  calls  uterine  castra- 
tion, to  ovariotomy;  he  finds  it  more  efficacious,  even  in  overcoming 
the  nervous  troubles,  than  removal  of  the  ovary.  His  theory  seems 
d  priori  untenable,  on  account  of  the  greater  richness  of  the  nerve 
supply  to  the  ovary ;  moreover,  oophorectomy  is  a  much  less  serious 
operation  than  hysterectomy. 

Techrdque  of  Ovariotomy. — I  have  already  described  this  opera- 


DISORDERS    OF   MENSTRUATION.  561 

tion  when  speaking  of  the  indirect  treatment  for  fibroids  (p.  316):  a 
few  special  points  are  worthy  of  notice  in  this  connection. 

The  abdominal  incision  should  be  as  small  as  possible,  since  only 
the  ovary  and  tubes  are  to  be  withdrawn  through  it,  and  there  is  no 
great  amount  of  groping  necessary,  nor  is  there  anything  to  remove 
that  offers  any  great  difficulty;  moreover,  it  is  always  an  easy  matter 
to  enlarge  the  wound  if  necessary.  From  two  and  a  half  to  three 
inches  is  large  enough ;  the  centre  of  the  incision  should  be  placed 
directly  over  the  fundus  of  the  uterus,  which  can  be  exactly  located 
by  bimanual  palpation;  the  inferior  end  of  the  wound  will  usually  be 
about  two  fingers'  breadth  from  the  pubes.  Battey,  at  least  in  his 
first  operations,  removed  the  ovary  only.  Hegar,77  in  the  very  begin- 
ning, realized  the  value  of  removing  the  tubes  as  well — a  procedure 
which  facilitates,  rather  than  adds  any  difficulty  to,  the  operation. 
Lawson  Tait78  also  considers  it  of  paramount  importance,  and  his 
opinion  has  had  great  influence  in  transforming  oophorectomy  into 
salpingo-oophorectomy. 

The  cicatrix  left  by  so  small  an  incision  as  that  made  by  Lawson 
Tait  is  unimportant,  especially  if  my  advice  be  followed  in  regard  to 
uniting  the  abdominal  walls  by  three  successive  layers  of  buried  cat- 
gut suture. 

Vaginal  incision  possesses  no  particular  advantages.  Yet  if  the 
patients  object  decidedly  to  an  abdominal  cicatrix,  it  may  be  used,79 
especially  if  the  ovaries  are  prolapsed  and  easily  reached.  The  pro- 
lapse of  the  ovaries  may  be  recognized  by  vaginal  touch,  in  Douglas' 
cul-de-sa  c ;  and  by  the  two  characteristic  symptoms,  pain  during  de- 
fecation and  coition. 

If  the  uterus  be  freely  movable,  the  operation  is  of  extreme  sim- 
plicity. The  patient  is  placed  in  the  dorso-sacral  position,  a  short 
Simon  speculum  presses  down  the  fourchette,  the  cervix  is  brought 
into  view  by  a  tenaculum,  and  an  assistant  keeps  down  the  uterus  by 
pressing  upon  the  hypogastrium.  A  transverse  incision  about  two 
inches  long  is  made  in  the  posterior  cul-de-sac  as  near  as  possible  to 
the  uterus.  The  index  and  middle  finger  are  introduced  into  the 
pouch  of  Douglas  and  bring  down  the  ovary  and  tube,  about  which  a 
ligature  is  carried  with  a  blunt  needle,  and  tied  with  a  Tait's  knot. 
If  the  nervous  symptoms  are  very  marked,  it  is  better  to  remove  the 
appendages  of  both  sides,  even  if  one  ovary  only  be  prolapsed ;  for 
the  induced  menoDause  has  a  greater  therapeutic  value  than  removal 
of  the  displaced  organ.     Should  there  be  no  complication  and  no 

36 


562  CLINICAL   AND    OPERATIVE   GYNAECOLOGY. 

special  indication  for  drainage,  the  wound  can  be  completely  closed 
by  catgut  sutures. 

BIBLIOGRAPHY  AND  NOTES. 

1.  Tilt:  The  Change  of  Life,  London,  1870,  3d  ed.  Cohnstein:  Deutsche  Klin., 
1873,  No.  5. 

2.  Pueeh:  Des  Ovaires  et  de  leurs  Anomalies,  Paris,  1873.  See  a  discourse  by- 
James  Stirton:  Upon  the  Effect  of  Race  and  Climate  on  Menstruation.  Glasgow 
Med.  Journal,  July,  1887.  Upon  the  influence  exerted  by  the  constitution,  and  by 
the  color  of  the  hair,  see  Sullies:  Ueber  die  Zeit  des  Eintritts  der  Menstruation. 
Dissert.  Inaug.,  KCnigsberg,  1886.  According  to  this  author,  large,  blonde  women 
menstruate  earlier  than  others. 

3.  Campbell,  cited  by  F.  Mtiller:  Die  Krankh.  des  weibl.  Korpers,  1888,  p.  226. 

4.  Prochownick:  Fall  von  Menstr.  precox  m it  Sectionsbericht.  Arch.  f.  Gyn., 
vol.  xvii.,  1881. 

5.  Kussmaul :  Yon  dem  Mangel,  etc.,  p.  42. 

6.  Rowlet:  Amer.  Jour,  of  Medical  Sciences,  1834,  p.  266.  Macnamara:  Lancet, 
December  12th,  1873.     Cortis:  Med.  Times,  April,  1863. 

7.  Fox.  quoted  by  Harris:  Amer.  Journal  of  Obstet.,  vol.  hi.,  p.  616.  Willard: 
Ibid.,  p,  638. 

8.  Horwitz:  Petersburg  Med.  Zeitung,  Bd.  xiii.,  p.  221.  In  this  article  will  be 
found  a  review  of  most  of  the  cases  known  at  the  time  it  was  written;  the  history 
might  be  filled  out  by  Wallentin's  work,  given  below.  Here  is  an  outline  of  the 
cases  most  recently  reported.  A.  Van  Derveer:  Amer.  Jour,  of  Obstetrics,  1883,  p. 
1,008.  Child  who  has  menstruated  since  the  age  of  four  months;  menses  appear 
every  twenty-eight  days,  lasting  four  or  five  days.  At  the  age  of  two  years  and 
seven  months  she  looked  like  a  girl  of  ten  or  twelve  years  ;  breasts  and  external 
genitals  well  developed.  Cabade :  Gazette  Medicale  de  Paris,  October  6th,  1883. 
Girl  who  menstruated  at  eight  months.  Rapid  development  of  external  genitals. 
"Wallentin:  Dissert.  Inaug.,  Breslau,  1886.  Menses  appeared  at  one  year  and  three 
months.  Breasts  and  external  genitals  well  developed.  The  child  was  very  large 
for  six  and  a  half  years.  Height  forty-eight  inches,  weight  sixty  pounds,  whereas, 
according  to  Gehrard,  the  average  height  for  a  child  of  six  years  is  thirty-nine 
inches  and  Aveight  forty-two  pounds.  This  work  contains  a  report  of  all  cases 
known  up  to  date,  Casati :  II  Roceoglitore,  October  30th,  1886.  Rachitic  child, 
who  began  to  menstruate  at  six  years  one  month.  Breasts  and  external  genitals 
well  developed.  Rectal  touch  showed  a  uterus  pubescens.  Loriot :  Annales  de 
Gynecologie,  April,  1887.  Little  girl  of  four  years  menstruating.  Reported  to 
Societe  de  Gynecologie  de  Paris.  Bernard:  Lyon  Medical,  August  14th,  1887. 
Young  girl  who  had  menstruted  from  birth  until  the  age  of  twelve  without  devel- 
opment of  genital  organs.  Profound  mental  emotion  upon  the  part  of  the  patient 
caused  its  disappearance,  and  it  afterward  came  at  irregular  intervals.  She  married 
at  the  age  of  twenty,  contracted  syphilis  from  her  husband  and  died  at  twenty-seven 
years  from  cancer  of  the  uterus.  Bernard  questions  (without  a  plausible  reason, 
however)  whether  the  precocious  menstruation  could  have  predisposed  her  to  can- 
cer. Diamant:  Intern.  Klin.  Rundschau,  1888,  No.  40.  Child  of  six  years  with 
breasts  and  external  genitals  as  fully  developed  as  a  girl  at  puberty.  Dentition  was 
complete  at  the  end  of  the  first  year;  at  the  age  of  two  years  menstruation  began, 
lasting  four  days.  At  six  years  the  menses  stopped  and  had  not  yet  appeared 
when  the  child  was  examined  six  months  later.  Epileptiform  attacks  replaced  the 
menstrual  periods.  Kornfeld  :  Centr.  f.  Gym,  1888,  p.  395.  Child  of  three  years, 
whose  father  was  insane  and  had  taught  her  to  masturbate.     Menses  appeared  for 


DISORDERS    Or   MENSTRUATION.  563 

three  months;  no  further  details  obtainable;   masturbation;   normal  mental  con- 
dition. 

9.  Beigel  :  Krankh.  der  weibl.  Geschlechtsorgane,  vol.  1.     Obs.  of  Flint  South. 

10.  Siredey:  Article  Menorrhagie  in  Diet,  de  M6d.  et  de  Chirurg.  Pratique  de 
Jaccoud. 

11.  Bari6:  Etude  sur  la  Menopause.  These  de  Doctorat,  Paris,  1877.  Kisch  : 
Das  klimakt.  Alter  bei  Frauen,  p.  44.  Barker  :  Phil.  Med.  Times,  December  12th, 
1874.  Knox:  Menstruation  in  Old  Age.  Medical  Record,  1888,  jSo.  9,  p.  538.  A. 
Marx  (Przeglad  Lekarski,  1889)  reports  a  case  where  menstruation  appeared  at  the 
age  of  forty-eight  and  lasted  regularly  for  four  years. 

12.  "Warnel  refers  to  a  case  which  strikingly  illustrates  the  necessity  for  local 
examination  where  there  is  amenorrhoea:  Obstet.  and  Gyn.  Soc.  of  Moscow;  re- 
viewed in  Annales  de  Gyn.,  January,  1890,  p.  43.  The  patient  was  a  multipara  of 
fifty-three  years,  in  whom  the  menses  stopped  very  suddenly.  An  abdominal 
tumor  made  its  appearance,  and  the  patient  died  of  peritonitis,  in  spite  of  an  at- 
tempt to  evacuate  through  the  vagina  the  blood  which  was  retained  in  the  uterus. 
The  cervix  was  obliterated,  and  this  atresia  was  probably  due  to  a  long-seatea 
stenosis  which  had  been  unrecognized. 

13.  Saint  Martin  (Journal  d' Accouchement  1888,  No.  18)  reports  a  case  where 
menstruation  persisted  all  through  pregnancy,  and  another  in  a  woman  of  twenty- 
four  who  had  never  menstruated. 

14.  L.  Mayer:  Berlin.  Beitr.  zur  Geb.  und  Gyn.,  ii.,  p.  124.  Raciborski:  Traite 
de  la  Menstruation,  Paris,  1861. 

15.  Storer:  Amer.  Jour,  of  Med.  Sciences,  Jan.,  1866,  p.  119.  Yoss  (Sweden)  : 
Centr.  f.  d.  med.  Wissensch.,  November  27th,  1869.  Goodmann:  Richmond  and 
Louisville  Med.  Jour.,  1875,  and  Annales  de  Gyn.,  1876.  Terrier:  Gazette  Hebdom., 
December  15th,  1876,  and  December  25th,  1878.  Malins:  British  Med.  Jour.,  1880. 
Ormieres:  Sur  la  Menstruation  apres  FOvariotomie  et  FHystgrectomie.  These  de 
Doct.,  1880  (Ormieres  has  collected  forty-five  cases).  Campbell:  Amer.  Gyn.  Soc. 
of  Philadelphia,  September,  1885;  Centr.  f.  Gyn.,  1884,  348.  Hennig:  Ueber  Men- 
struation nach  doppelter  Oophorotomie.  Obst.  Soc.  of  Leipsic,  November,  1887,  in 
Centr.  f.  Gyn.,  1888,  p.  360.  Tuttle:  Regular  Menstruation  after  Tait's  Operation. 
Amer.  Jour,  of  Obstet.,  1888,  p.  612.  Bantock  (British  Gynsec.  Journal,  February, 
1889)  quotes  several  cases  where  menstruation  persisted  for  a  long  time  after  abla- 
tion of  the  ovaries.  Macario,  Quenu,  Terrillon  :  Bull.  Soc.  de  Chir.,  1889,  p.  31. 
L.  Tait:  Menstruation  and  the  Ovaries.  Lancet,  1888,  ii.,  p.  104.  Roland  Pichevin: 
Des  Abus  de  la  Castration  chez  la  Femme.  These  de  Paris,  1888.  Glaevecke  (Arch, 
f.  Gyn.,  1889,  Band  xxxv.,  Heft  1)  has  reached  the  conclusion  that  menstruation 
ceases  completely  in  8S  cases  out  of  100,  immediately  after  removal  of  the  ovaries 
or  after  a  short  lapse  of  time.  In  12  out  of  100  cases  there  is  a  scanty  and  irregular 
flow.  In  50  per  cent  of  the  cases  the  molimen  persists,  and  about  the  same  pro- 
portion of  the  patients  develop  great  embonpoint. 

16.  Sanger,  out  of  49  cases  of  ovariotomy,  has  noted  only  two  where  the  men- 
strual flow  persisted;  in  one  of  them,  where  the  operation  was  done  for  a  retro- 
flexion complicated  by  endometritis,  the  surgeon  did  not  hesitate  to  open  the 
abdomen  a  second  time  to  ascertain  the  condition  of  the  stump;  there  was  not  a 
trace  of  the  appendages  to  be  found.  The  part  taken  by  the  endometritis  was 
revealed  by  the  fact  that  the  hemorrhages  disappeared  after  curetting.  In  the 
second  case,  ovariotomy  was  performed  for  multiple  myoinata.  Menses  persisted 
for  a  year  somewhat  less  in  amount.  Sanger  attributes  this  to  endometritis  and 
intends  to  curette.     Obstet,  Soc.  of  Leipsic.     Centr.  f.  Gyn.,  1888,  p.  361. 

17.  Czempin:  Zeits.  f.  Geb.  und  Gyn.,  Bd.  xiii.,  Heft  2. 

18.  Glaevecke:  KOrperliche  und  geistige  Veranderungen  in  weibl.  Korper  nach 
kunstl.  Verluste  der  Ovarien.     Arch.  f.  Gyn.,  1889,  Bd.  xxxv.,  Heft  1. 


564  CLINICAL  aXD  operative  gynaecology. 

19.  J.  L.  Charupionniere  (Repertoire  *Univers.  d'Obst.  et  de  Gynec.,  1888,  p.  220) 
quotes  a  case  where  menstruation  remained  perfectly  normal  after  a  double  sal- 
pingotomy, where  the  perfectly  healthy  ovaries  were  left  undisturbed. 

20.  Cohn:  Zur  Kasuistik  der  Amenorrhoe  bei  Diabetes  mellitus  und  insipidus. 
Zeitsch.  f.  Geb.  und  Gyn.,  Bd.  xiv.,  Heft  1,  1887.  Lecorche:  Du  Diabete  Sucre" 
chez  la-Femme,  Paris,  1886,  p.  171. 

21.  C.  H.  Carter:  Amenorrhcea  Associated  with  Alcoholism.  Brit.  Med.  Jour., 
1888,  p.  1,383. 

22.  Roller :  Ueber  das  .Verhalten  der  Menstr.  bei  Anwendung  von  Morphium 
und  Opium.     Berlin,  klin.  Woch.,  1888,  No.  48. 

23.  Dupuytren:  Lecons  Orales,  vol.  ii.,  p.  305,  and  Bull,  de  l'Acad.  de  Medec, 
September,  1838.  He  quotes  a  work  of  Brierre  de  Boismont,  which  was  thought 
worthy  of  a  prize  by  the  Academy,  in  which  he  discusses  the  influence  of  disease 
upon  menstruation.  Dupuytren  adds,  "We  have  often  noted  a  disturbance  or 
suppression  of  the  menses,  during  the  course  of  an  acute  or  chronic  surgical  affec- 
tion, or  after  a  major  operation."  (A  lengthy  discourse  follows,  upon  delay  or  ac- 
celeration of  the  function,  the  discharge  of  the  flow  through  the  wound,  etc.) 
This  study  has  been  taken  up  by  Terrillon.     Progres  Medical,  1874,  p.  737. 

24.  Fournier  :  Lecons  sur  la  Syphilis  chez  la  Femme,  Paris,  1873. 

25.  A.  F.  Currier:  The  Influence  of  Obesity  in  Young  "Women  upon  the  Men- 
strual and  Reproductive  Functions.     Med.  Record,  1888,  No.  6,  p.  162. 

26.  R.  J.  Robert  (British  Med.  Jour.,  November  16th,  1889)  gives  an  account  of 
a  case  where  fright  caused  the  return  of  a  flow  which  had  been  suppressed  for  nine 
months. 

27.  Raciborski :  Traite  de  la  Menstruation. 

28.  The  power  which  suggestion  possesses  upon  the  menstrual  fnnction  has 
been  proved  by  numberless  experiments.  I  saw  an  hysterical  patient  in  The 
Asylum  of  Villejif,  in  whom  Marcel  Briand  was  able,  by  suggestion,  to  cause  an 
advance  or  delay  of  several  days  in  menstruation.  Consult  Bernheim:  Sur  un  Cas 
de  Regularisation  de  la  Menstruation  par  Suggestion.  Arch,  de  Tocologie,  1887,  p. 
891.  Kobylinski:  Dysmenorrhea  Guerie  par  la  Suggestion.  Wracz,  1887,  No.  47. 
Hugenschmidt:  Treatment  of  Dysinenorrhcea  by  Mental  Suggestion  or  Hypnotism. 
Medical  and  Surgical  Reporter,  Philadelphia,  1888.  vol.  ix.,  p.  458. 

29.  W.  Levinstein:  Centr.  f.  Gyn.,  No.  40,  1887. 

30.  Abadie :  Traite"  des  Maladies  des  Yeux,  vol.  ii.,  1877.  Dehenne  :  Rapports 
Pathologiques  de  FOEil  et  de  FUterus.  Annales  de  Gyn.,  1879.  Mooren:  Gesichts- 
storungen  und  Uterinleiden.  Arch.  f.  Augenheilkunde,  Bd.  x.,  1881.  Karafiath  : 
Erblindung  mit  acuter  Papillo-retinitis  bedingt  durch  Ausbleiben  der  Menstrua- 
tion. Centr.  f.  Gyn.,  1884,  p.  270.  Clifton  S.  Morse:  New  York  Med.  Jour..  1887, 
January  22d,  p.  95. 

31.  J.  W.  Bowee:  Suppressio  Mensium  and  Paralysis  of  .Lower  Extremities,  Re- 
sulting from  Nostalgia;  Local  and  General  Faradization;  Cure.  Obstet.  Gazette. 
Cincinnati,  1888,  vol.  xi.,  p.  285. 

32.  Danlos:  Des  Eruptions  Cutanees  a  FEpoque  des  Regies.  These  de  Doct., 
1874.  G.  H.  Rose:  Amer.  Assoc,  of  Obstet.  and  Gyn.,  Sept.,  1888,  analyzed  in  Ann. 
de  Gyn.,  January,  1889,  p.  66.  Stiller:  Berlin,  klin.  Woch.,  1877.  No.  50.  Wilhelm: 
Ibidem,  1878,  No.  4.  Schramm:  Ibidem,  No.  42.  Wagner:  Allgem.  lued.  Central- 
zeitung,  No.  94.  Rouvier:  Ph^nomenes  Supplementaires  des  Regies.  Annales  de 
Gyn.,  1879.  Joseph:  Ueber  die  Beziehung  von  Dermatosen  in  Genitalkanaler- 
krankungen  des  Weibes.  Berlin,  klin.  Woch.,  1879.  J.  Heitzmann  :  Yicaraende 
Menstruation  und  Menstrual-Exanthem.     Wiener  med.  Jahrbucher.  1884.  Heft  1. 

33.  Borner:  Ueber  NervOse  Hautschwellung  als  Begleiterscheinung  der  Men- 
struation und  Climax.     Samml.  klin.  Vortr.,  1888,  No.  90,  p.  312. 

34.  Teplischin:  Med.  Rundschau,  1888,  No.  1. 


DISORDERS   OF   MENSTRUATION.  565 

35.  G.  E.  Jones:  Trans,  of  the  Obst.  Soc.  of  Cincinnati.  Amer.  Jour,  of  Obst., 
1887,  vol.  xx.,  p.  92. 

36.  This  curious  phenomenon  has  long  been  known.  Stahi  :  l)e  Mensium  Yiis 
Insolitis,  Halle,  1702.  A.  cle  Haller  (Elementa  Physiologite,  tome  vii.,  livre  xxviii., 
sect,  iii.,  IT  14,  Lausanne,  1778)  describes  with  accuracy,  quae  mensium  locum 
tenent.  Consult  Scanzoni :  Loc.  cit.,  p.  277.  Courty:  Loe.  cit.,  p.  473.  Puech  : 
Cotnptes  Rendus  Academ.  des  Sciences,  December  9th,  1801.  L.  Torthe:  D'Une 
Forme  Rare  de  Deviation  Menstruelle.  These  de  Paris,  1877.  Lorey :  Des  Vomisse- 
ments  de  Sang  supplementaires.     These  de  Paris,  1878. 

37.  Camiade:  These  de  Paris,  1872. 

38.  R.  Thomas :  Amer.  Jour,  of  Obst.,  1886,  p.  14.  C.  O.  Wright  (Amer.  Jour, 
of  Obst.,  1887,  xx.,  p.  88)  reports  three  cases. 

39.  Baratt:  London  Med.  Record,  reviewed  in  Archives  de  Tocologie,  1876. 

40.  Gilles  de  la  Tourette  (Progres  Medical,  1882,  No.  35)  reports  the  case  of  a 
girl  of  eighteen  years,  who  since  the  age  of  twelve  years  had  a  purulent  discharge 
from  the  ears.  At  the  age  of  fourteen  she  awoke  one  night  to  find  herself  bathed  in 
blood  which  had  escaped  from  them.  Since  that  time,  the  same  thing  has  occurred 
regularly  every  three  weeks;  once  only  the  menstrual  flow  occurred  in  the  normal 
manner.  Stepanow  (Med.  Rundsch.,  No.  19,  1885)  speaks  of  a  young  girl  of  seven- 
teen, an  hysterical  subject,  in  whom  the  tympanum  is  imperforate  and  the  ears 
are  in  an  apparently  sound  condition.  Yet  the  menstrual  flow  is  discharged  from 
them  and  lasts  two  days.  He  alludes  to  three  similar  cases  of  Meniere's  in  which, 
however,  the  ears  were  diseased,  and  to  cases  of  Jacobi,  Benni,  Henzinger,  Huss, 
and  Lang. 

41.  Stear  (Lancet,  May  13th,  1881)  observed  a  vicarious  menstruation  from  the 
mammary  glands;  woman  was  fifty  years  old;  the  hemorrhage  began  twelve 
months  previously.  Gordon  (Amer.  Jour,  of  Obst.,  April,  1882,  p.  343)  gives  the 
following  account:  Woman  forty-one  years  old,  of  vigorous  constitution.  For 
seven  years  past  the  menses  have  ceased,  and  the  flow  of  blood,  which  lasts  from 
three  to  five  days,  regularly  takes  place  from  a  small  blue  spot  at  the  inner  surface 
of  the  phalangeal  articulation  of  the  thumbs.  This  flow  was  interrupted  by  preg- 
nancy. 

42.  De  Sinewy  recommends  three-quarters  of  a  grain  each  of  aloes,  rue,  savine, 
and  saffron,  in  a  wafer,  of  which  one  or  two  may  be  taken  daily. 

43.  Apiol,  the  active  principle  of  Apium  petroselinum,  has  been  especially 
recommended  by  Joret:  Bull.  G<?n.  de  Ther.,  February,  1860,  and  Marotte:  Ibid., 
October,  1863.  It  is  administered  in  capsules  containing  four  grains  each;  one 
given  in  the  morning  and  one  at  night,  at  the  menstrual  period  if  there  be  dys- 
menorrhea, or  at  the  time  it  is  due  if  there  be  amenorrhea. 

44.  The  drastics  most  commonly  used  are  aloes,  scammony,  jalap,  podophyllum, 
caseara,  etc.  I  give  two  and  a  half  drachms  of  the  tinct.  jalap  co.  (eau  de  vie 
allemande)  in  a  cup  of  weak  coffee.  The  best  tolerated  saline  purgative  is  the 
citrate  of  magnesia  (about  §  iss.),  or  some  natural  mineral  water,  as  Hunyadi 
Janos,  Pullna,  Birmenstorff,  etc. 

45.  Boldt  (New  York)  :  Therapeutic  Gaz.,  1887,  Jan.  loth.  P.  W.  Macdonald : 
Permanganate  of  Potassium  in  the  Treatment  of  Amenorrhea  Associated  with 
Mental  Disease.  Practitioner,  London,  1888,  vol.  xi.,  p.  428.  Hart  and  Barbour 
(loc.  cit.)  give  this  formula  : 

B  Potassii  permanganatis, 

Kaolin aa  gr.  ij. 

Vaselini q-  s. 

Fiat  pilula  :  mitte  tales  xxiv. 
Sig.  One,  thrice  daily. 


566  CLIXICAL   AND    OPERATIVE   GYNAECOLOGY. 

46.  Watkins:  Arch,  de  Tocol.,  1887,  p.  514. 

47.  H.  Bigelow  :  Gynecological  Electro-Therapeutics,  London,  1889,  p.  159. 

48.  Lande :  Sur  une  Forme  de  Metrorrhagie  Provoquee  par  l'Allaitement. 
Journal  de  Med.  de  Bordeaux,  1879. 

49.  S.  Gottschalk  :  Archiv  f.  Gynak.,  xxxii.,  Heft  2,  p.  234  (pupil  of  Landau) 
recently  reported  a  curious  case  of  diseased  ovary  which  gave  rise  to  profuse 
hemorrhages ;  it  was  a  veritable  cavernous  metamorphosis.  The  uterus  and 
ovaries  were  removed  through  the  vagina. 

50.  Koteliansky  (Presse  Medicale  Beige,  1889,  p.  880)  describes  an  operation  of 
this  nature  done  by  Onoutrieff  with  the  best  results. 

51.  R  Freshly  pulverized  ergot,  3  L,  to  be  divided  into  eight  powders  ;  one  to 
be  taken  every  three  hours.  Tvon's  ergotin  can  be  given  hypodermatically  in 
doses  of  nix  v.,  two  or  three  times  in  the  twenty-four  hours;  but  it  is  inadvisable  to 
administer  strong  doses  of  ergot  for  any  length  of  time. 

52.  One  and  one-half  grains  of  the  digitalis  leaves  in  a  quart  of  water  to  be 
taken  during  the  twenty-four  hours. 

53.  Hofmeier,  quoted  Olshausen  :  Die  Krankheiten  der  Ovarien,  1886,  p.  449. 
Terrillon :  Soc.  Obst.  et  Gynecol.  (Repertoire  Universel  d'Obst.  et  de  Gyn.,  1888, 
pp.  194  to  208).     Lucas  Championniere,  ibidem. 

54.  Walton  :  Du  Drainage  de  la  Cavite  Uterine,  Gand,  1888. 

55.  Priestley  :  Cases  of  Intermenstrual  or  Intermediate  Dysmenorrhoea,  1871 
(reviewed  in  Jahresbericht,  1872,  vol.  ii.).  Fasbender :  Zeitschr.  fur  Geb.  und 
Frauenkr.,  p.  125.  Sorel :  Douleur  Hypogastrique  ou  Dysmenorrhea  Intermen- 
struelle.     Arch,  de  Tocol.,  March,  1887,  p.  269. 

56.  See  chapters  on  Endometritis  and  Stenosis  of  the  Cervix. 

57.  Paul  Tallin  :  Situation  et  Prolapsus  des  Ovaires.     These  de  Paris,  1887. 

58.  Dubois  :  Chloral  et  Bromure  de  Potassium  dans  la  Dysmenorrhea.  Gaz. 
Hebd.  des  Sci.  Med.  de  Bordeaux,  June  5th,  1888. 

59.  Courty  :  Traite  pratique  des  Maladies  de  TUterus,  1881,  p.  492,  recommends 
one  and  one-half  grains  of  asafetida  in  pill  form  hourly,  or  25  to  30  drops  of  an 
antispasmodic  mixture  composed  of  1  3  20  gr.  each  of  tincture  of  valerian,  tincture 
of  castoreum,  and  Sydenham's  laudanum. 

60.  Schaw:  The  Value  of  Belladonna  and  Hyoscyamus  in  Dysm.  Lancet,  1888, 
ii.,  p.  570. 

61.  Dettenbauch  :  Med.  Record,  May  21st,  1887.  Windelschmidt :  Allg.  med. 
Centr.  Zeit.,  Berlin,  1888,  vii.,  p.  1,829. 

62.  Chambers:  Oxal.  of  Cerium  in  Dysm.    Med.  Record,  New  York,  1888,  No.  34. 

63.  Wylie  :  The  American  System  of  Gynecology,  vol.  v. 

64.  Routh  :  Sajous'  Annual,  1889. 

65.  Battey  :  Normal  Ovariotomy.  Atlanta  Med.  and  Surg.  Journal,  Sept., 
1872.     His  first  operation  was  performed  Aug.  17th,  1872. 

66.  Hegar:  Die  Castration  der  Frauen.  Volkmann's  klin.  Vortrage,  Gyn.,  42, 
Leipsic.  1878.  His  first  operation  was  done  July  27th,  1872,  and  therefore  pre- 
ceded Battey's  by  one  month.  But  Hegar's  patient  died  of  peritonitis,  and  he  did 
not  repeat  the  operation  until  Aug.  2d,  1876,  long  after  Battey  had  made  known 
the  operation  which  bears  his  name. 

07.  Lawson  Tait :  British  Med.  Jour.,  May  31st,  1879.  Diseases  of  the  Ovaries, 
1883,  p.  327.     His  claim  to  priority  (Medical  News,  July,  1886,  p.  26)  is  untenable. 

68.  R.  Battey  (of  Rome,  Georgia) :  What  is  the  Field  of  Battey's  Operation  ? 
Article  read  before  the  American  Gynecological  Society  of  Cincinnati,  quoted  by 
By  ford.  The  Practice  of  Medicine  and  Surgery  Applied  to  the  Diseases  and  Acci- 
dents Incident  to  Women,  4th  edit.,  Phil.,  1888,  p.  672. 

69.  Olshausen  :  Die  Krankheiten  der  Ovarien,  1886,  p.  452. 


DISORDERS    OF   MENSTRUATION.  567 

70.  Heilbrunn,  Walton,  V.  Hoffmann,  Bircher,  Hegar,  etc.  See  bibliographi- 
cal references  farther  on. 

71.  J.  Friedmann,  L.  Landau  and  Remak,  A.  Leppmann,  Munde,  etc. 

72.  Israel:  Beitrage  zur  Wtirdigung  des  Werthes  der  Castration  bei  hysteri- 
schen  Frauen.  Berlin,  klin.  Wochenschr.,  1880,  IN'o.  17.  Hegar :  Zur  IsraeTschen 
Scheincastration.  Berlin,  klin.  Wochenschr.,  1880,  No.  48.  Chiarleoni  (Gazzetta 
degli  Ospitali,  1888,  Nos.  8,  9,  in  the  case  of  a  hysterical  patient  of  29  years 
(amenorrhoea,  obstinate  vomiting,  extreme  emaciation),  pretended  to  perform  an 
ovariotomy,  by  making  a  superficial  incision  in  the  abdomen.  Vomiting  ceased 
immediately,  sleep  and  appetite  returned.  The  patient  left  her  bed  fifteen  days 
after  the  operation  ;  the  menses  appeared  a  month  later. 

73.  Goodell  :  Extirpation  of  the  Ovaries  in  a  Woman  Suffering  from  Nym- 
phomania and  Incorrigible  Masturbation,  with  the  Object  of  Preventing  Propaga- 
tion of  this  Mania.     New  York  Medical  Record,  October  13th,  1883. 

74.  Hegar  (Hegar  and  Kaltenbach  :  Operative  Gyn.,  3d  edit.,  1886)  recognizes 
this  fact  when  he  says,  "  We  have  often  obtained  lasting  results  from  ovariotomy, 
in  cases  where  a  careful  examination  has  failed  to  reveal  anything  except  a  hyper- 
plasia of  the  stroma  of  the  ovary,  or  a  slight  peri-oophoritis."  These  lesions  are  of 
small  importance;  he  might  as  well  say  at  once  that  ovariotomy  was  often  success- 
ful when  the  ovaries  were  healthy. 

75.  Bibliographical  references  relative  to  the  recent  performances  of  ovariotomy 
for  dysmenorrhea  accompanied  by  nervous  and  mental  derangements.  R.  Battey : 
Trans,  of  the  Ainer.  Gyn.  Soc,  1876.  M.  Sims  :  British  Med.  Journal,  Dec,  1877. 
Borner :  Wiener  med.  Wochenschr. ,  1878,  Nos.  47-50.  Oweling  :  Obst.  Jour,  of 
Great  Britain,  Jan.,  1879.  F.  Franzolini:  Gaz.  Med.  Italiana,  prov.  Venete,  xxii., 
No.  38.  Dawson:  Amer.  Jour,  of  Obst.,  1881,  p.  419.  Munde:  Ibid.,  1883,  p.  944. 
Carstens  :  Ibid.,  1883,  pp.  266  and  522.  Perette:  Berlin,  klin.  Wochensch.,  1883,  No. 
10.  Klotz  :  Hysterie  und  Castration.  Wien.  med.  Wochenschr.,  1882,  Nos.  38-41. 
W.  Goodell :  Amer.  Jour,  of  Insanity,  1882,  1-4,  and  Phila.  Med.  Times,  December 
29th,  1883.  Maurer  :  Deutsche  med.  Wochens.,  vii.,  1882,  p.  530.  Jesset :  Lancet, 
June,  1882.  Landau  and  Remak  :  Zeitschr.  fur  klin.  Med.,  vi.,  5,  1883,  p.  437.  G. 
Thomas  :  New  York  Med.  Jour.,  January,  1883.     Bern.  Heilbrunn  :  Centr.  f.  Gyn., 

1883,  No.  38.  Malins:  British  Med.  Jour.,  May  12th,  1883.  Walton  :  Boston  Med. 
and  Surg.  Journal,  1884,  No.  23.  V.  Hoffmann  :  San  Francisco  Western  Lancet, 
January,  1884.  Flechsig :  Neurol.  Centralbl.,  1884,  Nos.  19  and  20.  Bircher:  Cas- 
tration bei  Ovariel  Neuralgie  und  Hysterie.  Correspblatt.  f.  Schw.  Aerzte,  1884. 
Julius  Friedmann :  Vergleich  einiger  Falle  von  Operat.  an  den  Ovarien  wegen  Psy- 
chose.     Inaug.  Dissert.,  Berlin,  1883.     Hegar  :  Archiv  f.  Gyn.,  xxiv.,  Cent.  f.  Gyn., 

1884,  p.  593.  Zur  Castration  bei  Hysterie.  Berlin,  klin.  Woch.,  1880,  No.  26.  Zur 
Begriffsbest.  der  Castration.  Cent.  f.  Gyn.,  1887,  No.  44.  Der  Zusammenhang  der 
Geschlechtskrankheiten  mit  nervosen  Leiden,  1885.  Spencer  Wells  :  Case  of  Re- 
moval of  Both  Ovaries  for  Dysmenorrhcea.  Trans,  of  the  Amer.  Gyn.  Soc,  vol. 
iv.,  p.  198  L.  Tait :  The  Pathology  and  Treatment  of  Diseases  of  the  Ovaries,  p. 
328.  Schmalfuss :  Zur  Castration  bei  Neurosen.  Arch.  f.  Gyn.,  1885,  Band  xxvi., 
p.  T.  Menzel :  Beitrage  zur  Castration  der  Frauen.  Arch.  f.  Gyn.,  1885,  Bd.  xxvi., 
p.  36.  Tissier  :  De  la  Castration  de  la  Feinme  en  Chirurgie.  These  de  Paris,  1885. 
Uherek :  Arch.  f.  Gyn.,  xxvii.,  3.  L.  Tait :  British  Medical  Jour.,  1886,  p.  852.  A 
Case  of  Hystero-epilepsy  Successfully  treated  by  Removal  of  Damaged  Uterine 
Appendages.  Lancet,  1887,  ii. ,  p.  1,213.  Taufeer  :  Beitrage  zur  Lehre  der  Castra- 
tion der  Frauen.  Zeitsch.  f.  Geb.  und  Gyn.,  Bd.  ix.,  Heft  1.  Schroder:  Ueber  die 
Castration  bei  Neurosen.  Zeits.  f.  Geburts.  und  Gyn.,  Bd.  xiii.,  Heft  2.  Leopold: 
Archiv  f.  Gyn.,  Bd.  xx.,  p.  88.  Fehling :  Zehn  Castrationen.  Archiv  f.  Gyn.,  Bd. 
xxii.,  Heft  3.     Bruntzel :  Arch,  f.  Gyn.,  Band  xiv.     Widmer :  Centr.  f.  Gyn.,  1886, 


568  CLINICAL   AND   OPERATIVE   GYNAECOLOGY. 

No.  40.  Munde  :  Amer.  Jour,  of  Obstet.,  vol.  xix.,  March,  1880,  and  vol.  xxi.,  p.  35, 
January,  1888.  Schramm:  Ueber  Castration  bei  Epilepsie.  Berlin,  klin.  Woch., 
1887,  No.  8.  Mtiller:  Beitrage,  etc.  Deutsche  Zeitschr.  f.  Chir.,  Bd.  xx.  Gustav 
Willers  :  Ueber  die  Berechtigung  der  Castr.  der  Frauen  zur  Heilung  von  Neurosen 
und  Psychosen.  Dissert.  Inaug.,  Freiburg,  1887.  Lucas  Championniere  :  Ti*ois  Cas 
d' Ablation  des  Ovaires  pour  Accidents  Nerveux.  Soc.  Obst.  et  Gyn.  de  Paris  in 
Annales  de  Gyn.,  xxvii.,  p.  450.  E.  W.  Cushing:  Melancholia,  Masturbation  Cured 
by  Removal  of  both  Ovaries.  Jour,  of  the  Amer.  Mecl.  Assoc,  Chicago,  1887,  p. 
441.  Magnin:  De  la  Castration  chez  la  Femme  comme  Moyen  Curatif  des  Troubles 
Nerveux.  These  de  Paris,  1886.  Reamy:  A  Case  of  Oophorectomy  for  Epilepsy. 
Americ.  Jour,  of  Obstet.,  vol.  xxi.,  p.  435.  F.  Merkel :  Beitrage  zur  Kasuistik  der 
Castration  bei  Neurosen,  Nuremberg,  1888.  May:  A  Case  of  Hystero-epilepsy ; 
Tait's  Operation ;  Cure.  Virginia  Med,  Monthly,  Richmond,  1888-89,  xv.,  p.  174. 
Imlach :  A  Case  of  Hystero-epilepsy  of  Twenty  Years'  Duration  Treated  by  Re- 
moval of  the  Uterine  Appendages.     British  Med.  Jour.,  1888,  i.,  p.  140. 

76.  Pean  :  Gaz.  des  Hop.,  1886,  No.  145. 

77.  Hegar  :  Die  Castration  der  Frauen. 

78.  Tait  :  Diseases  of  the  Ovaries,  1883,  p.  326. 

79.  Bonnecaze  :  Valeur  et  Indication  de  l'lncision  Vaginale  Appliqu^e  a  1' Ab- 
lation de  certaines  petites  Tumeurs  de  l'Ovaire  et  de  la  Trompe.  These  de  Paris, 
1889. 


INDEX. 


Abdominal  bandages,   185 

girdle,  422 

palpation,  simple,  91 

palpation,  sources  of  error  in,  93 
Accidents  after  the  use  of  the  curette, 
199 

of  enucleation  of  fibromata,  264 
Acquired  atresia  of  the  cervix,  532 
Acute  metritis,  134,  177 

septic  metritis,  137 
Adenoma  of  the  uterus,  396 
Air  cushion,  perineal,  494 
Albumin  in  the  urine  after  chloroform,  36 
Alcohol  for  cleaning  the  hands,  2 
Alexander's  operation,  453 

mortality  of,  455 

reposition  of  the  uterus  in,  453 

results  of,  455 
Alquie"  Alexander- Adams  operation,  452 
Amenorrhoea,  547 

cutaneous  eruptions  in,  551 

etiology  of,  547 

pathology  of,  547 

primary,  550 

secondary,  550 

symptoms  of,  551 

treatment  of,  552 
Amputation  of  the  cervix,  conical  inci- 
sion, 207 

in  chronic  metritis,  205 

intra-vaginal,  354 

Schroder's  operation,  208 

with  a  single  flap,  209 

with  two  flaps,  207 
Anaesthesia,  effects  of  prolonged,  35 

in  examinations,  33 

in  gynaecology,  31 

mixed,  33 

position  of  patient  during,  37 
Anteflexion,  acquired,  424 

amenorrhoea  in,  427 

congenital,  424 

diagnosis  of,  428 

dilatation  of  the  cervix  in,  430 


Anteflexion,  dyspareunia  in,  4^8 

etiology  of,  423 

hypertrophy  of  the  cervix  in,  425 

infantile,  425 

pathology  of,  423 

stem  pessaries  in,  431 

symptoms  of,  427 

treatment  of,  429 

varieties  of,  424 
Anteversion  of  the  uterus,  419 

pessaries,  421 
Antiphlogistic  tamponade,  80 
Antisepsis,  beta-naphthol  in,  7 

in  gynaecology,  1 

in  laparatomy,  17 

in  operations  through  natural  pas- 
sages, 1 

in  passing  the  uterine  sound,  108 

of  external  genitals,  3 

ox  the  cervix  and  uterine  cavity,  12 
Apostoli's  treatment  of  fibroma,  250 

uterine  electrodes,  251 
Applicator,  Sims1  slide,  190 
Artery,  uterine,  ligation  of,  in  uterine 

dilatation,  117 
Artificial  dilatation  of  the  uterus,  111 
Atomizer,  Collin's  rotary,  20 
Atresia  of  the  cervix,  532 
Atrophy  of  the  cervix,  532,  538 

of  the  glands  in  interstitial  metritis, 
142 

of  the  uterus,  acquired,  540 
congenital,  538 

Bacteria  in  metritis,  159 

Bandages,  abdominal,  185 

Bath  speculum,  186 

Battey's  operation,  influence  of,  on  men- 
struation, 549 

Bed-pan,  Baker's,  9 
French  pattern,  8 

Beta-naphthol,  7 

Bichloride    solution,    Laplace's    experi- 
ments with,  6 


570 


INDEX. 


Biilroth's  forceps,  67 

Bimanual  exploration,  96 

Bimanual  reduction  of  retroflexion,  441 

Bloodless  method  of  dilating  the  uterus, 
112 

Bozeman-Fritseh    catheter     for    intra- 
uterine injections,  14 

Breslau  obstetrical  clinic,  use  of  creolin 
in,  6 

Brewer's  speculum,  102 

Broad  ligaments,  ligation  of,  in  vaginal 
hysterectomy,  865 
forceps  for  compression  of,  in  vagi- 
nal hysterectomy,  368 

Bromide  of  ethyl  in  local  anaesthesia,  31 

Budin's    horseshoe  catheter    for  intra- 
uterine injections,  15 

Bumm,   creolin  in  Breslau    obstetrical 
clinic,  6 

Cancer  of  the  cervix,  333 

anatomical  forms  of,  334 

cardiac  lesions  in,  341 

cauterization  in,  386 

causes  of  death  after  vaginal  hyster- 
ectomy for,  372 

complicating  fibroma,  389 

complicating  pregnancy,  345,  388 

diagnosis  of,  345 

drainage  after  hysterectomy  for,  370 

dressing  after  hysterectomy  for,  366 

eating,  335 

etiology  of,  349 

exceptional  cases,  347 

extending  to  vagina  and  bladder,  384 

extension  of,  338 

histological  varieties,  836 

hysterectomy  in,  360 

infiltrated,  335 

invading  the  vagina,  383 

local  predisposing  causes  of,  352 

modifications  of  hysterectomy  for, 
367 

mortality  after  hysterectomy,  371 

metastasis  in,  342 

nodular  form  of,  335 

palliative  treatment  for,  384 

papillary,  334 

parenchymatous,  335 

pathology  of,  333 

prognosis,  349 

statistics,  850 

statistics  of  hysterectomy  for,  374 


Cancer,  survival  after  hysterectomy  for, 
374 

symptoms  of,  343 

treatment  of,  353 

uraemia  in,  844 

vaginal  form  of,  335 

with  cyst  of  the  ovary,  390 

with  deep  extension,  383 
Cancer  of  the  entire  cervix,  statistics  of, 

358 
Cancer  of  the  entire  cervix,  treatment 

of,  356 
Cancer  of  the  fundus  uteri,  396 

anatomical  forms,  398 

diagnosis  of,  404 

etiology  of,  405 

Freund's  operation  in,  411 

histology  of,  400 

statistics  of  hysterectomy  for,  413 

symptoms  of,  402 

treatment  of,  410 

uterine  syndrom  a  in,  402 
Cancer  of  the  uterus,  adenopathy  in,  342 

cauliflower,  334 

Kraske's  operation  for,  380 

lymph  ganglia  in,  342 

metastasis  in,  342 

renal  disease  in,  339 
Cancerous  degenei'ation  of  fibroma,  228 
Canulse  for  vaginal  injections,  8 
Carriage  for  transporting  patients,  35 
Castration,  evisceration  in,  321 

for  fihroma,  316 

for  fibroma,  mortality  of,  323 

for  fibroma,  results  of,  823 

for  fibroma,  statistics  of,  323 

for  fibroma,  unilatex^al,  823 

for  metritis,  212 

ligature  of  the  vessels  in,  322 
Catarrhal  metritis,  177 
Catgut,  preparation  and  preservation  of, 

25 
Catheters  for  the  ureters,  Pawlik's,  125 
Catheterism    of    the    ureters,    Pawlik's 
method,  123 

Simon's  method,  127 
Caustic  applications  in  metritis,  188 

injections  in  metritis,  193 
Cauterization,  intra-uterine,  191 

of  wounded  surfaces,  214 
Cervical  cavity,  cancer  of  the,  335 

granulations,  150 

laceration,  consequences  of,  164 


INDEX. 


571 


Cervical  metritis,  147 
scarificators,  187 
stenosis,  diagnosis  of,  535 
stenosis,  stomatoplasty  in,  508 

stenosis,  treatment  of,  585 

ulceration,  treatment  of,  200 
Cervix,  amputation  of,  in  chronic  metri- 
tis, 205 

antisepsis  of,  12 

atresia  of  the,  532 

atrophy  of  the,  532 

bilateral  division  of,  in  uterine  dila- 
tation, 117 

bilateral  section  of  the,  in  fibroma, 
256 

cancer  of,  complicating  pregnancy, 
388 

cancer  of,  extending  to  vagina  and 
rectum,  384 

cancer  of,  prognosis  of,  349 

cancer  of  the,  333 

cancer  of  the,  symptoms  in,  343 

congenital  atrophy  of  the,  538 

conoidal  amputation  of  the,  486 

cylindrical  epithelioma  of  the,  336 

dilatation  of  the,  in  fibroma,  256 

ectropion  of  the,  152 

Emmet's  operation   for   laceration, 
209 

erosion  of,  150 

fibroma  of,  surgical  treatment  of,  257 

fibroma  of  the,  219 

follicular  hypertrophy  of  the,  152 

granulations  of,  150 

hypertrophy  of  the,  532 

hypertrophy  of  the,  in  anteflexion, 
425 

laceration  of,  154 

malformations  of  the,  533 

mucous  polypi  of  the,  153 

pavement  epithelioma  of  the,  336 

rapid  dilatation  of,  116 

stenosis  of  the,  533 

stenosis  of  the,  diagnosis  of,  535 

subdivisions  of  the,  486 

ulceration  of,  150 
Chadwick's  table,  86 
Chamberland  filter,  .purity  of  water  fil- 
tered through,  23 
Chloroform,  administration  of,  33 

albumin  in  urine  after  administra- 
tion of,  36 

in  ovariotomy,  36 


Chronic  glandular  metritis,  142 
interstitial  metritis,  141 
metritis,  137 

painful  metritis,  178,  203 
polypous  metritis,  143 
Classification  of  pseudo-metritis,  131 
Cleansing  of  the  uterus  in  metritis,  189 
Cleveland's  operating-table,  88 
self-retaining  speculum,  105 
Cocaine  in  local  anaesthesia,  31 

objections  to,  32 
Coitus,  excessive,  as  a  cause  of  metritis, 

162 
Collin's  catheter  for  intra-uterine  injec- 
tions, 14 
needle-holder,  43 
rotary  atomizer,  20 
tumor  forceps,  259 
Colpocleisis,  507 

results  of,  510 
Colpo-hysterectomy  for  fibroma,  273 
for  retro-deviations,  456 
in  cancer  of  the  cervix,  360 
Colpo-hysteropexy,    pelvic,  in  retro-de- 
viations, 458 
Colpo-perineoplasty  by  Doleris'  method, 
502 
by  flap-splitting,  502 
Colpo-perineorrhaphy,  after-treatment, 
510 
by  Martin's  method,  501 
in  genital  prolapse,  498 
results  of,  510 
Colporrhaphy  in  genital  prolapse,  497 
Columnization  in  metritis,  204 
Complete  bilateral  division  of  the  cervix 

in  uterine  dilatation,  117 
Congenital  atresia  of  the  cervix,  53 

atrophy  of  the  cervix,  538 
Conoidal  amputation  of  the  cervix,  486 
Construction  of  instruments,  2 
Continuous  irrigation  during  operation, 
16 
local  anaesthesia  from,  32 
with  long  nozzle  during  operation,  17 
Course  of  metritis,  180 
Crayons,  Yon  Hacker's,  13 
Creolin,  Bumm's  report  on,  6 
Curettage,  194 

Curette,  accidents  after  the  use  of  the, 
199 
perforation  with,  199 
Curettes,  cutting,  885 


572 


INDEX. 


Curetting,  exploratory,  119 

in  fibroma,  256 

in  hemorrhagic  metritis,  203 

in  the  treatment  of  metritis,  134 
Cuseo's  speculum,  102 
Cutter's  treatment  of  fibroma,  251 
Cylindrical  speculum,  101 
Cyst  forceps,  dentated,  270 
Cystocele,  481 

Stoltz's  tobacco-pouch  operation  for, 
508 

Daxgerotts  zone,  Winters,  100 
Dastre*s  experiments  on  mixed  anaesthe- 
sia, 34 
Decidua  menstrualis,  179 
Depressor,  Sims1,  105 
Deviations  of  the  uterus,  treatment  of, 
420 

symptoms  of,  420 
Disinfection  of  instruments,  3 
Dilatation  of  the  cervix  for  stenosis,  535 

of  the  uterus,  111 

of  the  uterus,  immediate  progressive, 
115 

of  the  uterus,  incision  of  external  os, 
in  rapid,  116 
Dilator,  uterine,  GoodelTs,  115 

uterine,  Palmer's,  115 
Diphtheritic  metritis,  146 
Disorders  of  menstruation,  547 
Displacements  of  the  uterus,  416 

anterior,  419 

ligaments  of  the  uterus  in,  416 

classification  of,  417 

diagnosis  of  posterior,  435,  439 

etiology  of  anterior,  419 

etiology  of  posterior,  434 

pathology  of  posterior,  435 

positional  reduction  of  posterior,  440 

posterior,  434 

salpingitis  in  posterior,  438' 

treatment  of  posterior,  435,  439 

upward,  473 

uterine  syndroma  in  posterior,  438 
Divulsion,  114 
Doderlein's    studies    on    germs   in   the 

lochia,  159 
Polaris1  ecouvillon,  191 
Drainage,  indications  for,  71 

in  metritis,  189 

intra -uterine,  77 

lamp  wick  for,  74 


Drainage  of  peritoneal  cavity,  69 

of  wounds,  68 

tube,  Tait's  aspirator  for,  73 

tubes,  28 
Dressing  forceps,  200 
Duck-bill  speculum,  102 
Dumontpallier's  ring  pessary,  422 
Dysmenorrhea,  555 

diagnosis  of,  556 

influence  of  the  menopause  on,  559 

inter-menstrual,  556 

membranous,  138,  179 

obstructive,  534 

opiates  in,  558 

ovariotomy  in,  560 

symptoms  of,  556 

technique  of  ovariotomy  in,  561 

treatment  of,  558 

vaginal  ovariotomy  in,  561 

EcorviLLo^v,  Doleris',  191 
Ectropion  of  the  cervix,  152 
Eiselsberg's  researches  on  substances  for 

cleaning  the  hands,  1 

experiments  on  iodoform  gauze,  11 
Elastic  abdominal  girdle,  422 

ligature,  28,  60 

ligature,  dropped,   in  supra-vaginal 
hysterectomy,  292 

ligature,  forceps  for,  59 
Electrolysis  in  fibroma,  249 

hi  stenosis  of  the  cervix,  537 
Elytroiihaphy,  501 

anterior,  506 
Emmet's     operation     compared     with 

Schroder's,  202 
Endometritis  (see  Metritis) 

acute,  138 

chronic  polypous,  143 

post  abortum,  147 
Engorgement,  uterine,  151 
Epithelioma  of  the  body  of  the  uterus, 
398 

of  the  cervix,  336 

of  the  fundus  uteri,  400 

of  the  fundus  uteri,  diagnosis  of,  404 

of  the  fundus  uteri,  pathology  of, 
399 
Erosion,  complicated  by  laceration  of 
the  cervix,  200 

of  the  cervix,  150 
Eruptions,  cutaneous,  in  amenorrhoea, 
551 


INDEX. 


573 


Ether  as  general  anaesthetic,  33 

Examination  by  speculum,  100 
anaesthesia  in,  33 
gynaecological,  84 

Exfoliating  endometritis,  179 

Exploration,  bimanual,  00 
of  the  ureters,  120 
of  ureters,  Narkalla's  method,  128 
of  ureters,  Pawlik's  method,  123 
of  ureters,  Simon's  method,  127 

Exploratory  curetting,  11£ 
incision,  uterine,  119 

External  genitals,  antisepsis  of,  3 

os,  cancer  of  the,  treatment  of,  353 
os,  division  of  the,  in  stenosis,  536 

Fallopian  tubes,  can  uterine  sound  be 

passed  into  the  ?  109 
Fenestrated  canula  for  injection,  8 

speculum  for  injections,  8 
Fibroma,  ascites  from,  243 

cancerous  degeneration  of,  228 
cardiac  pressure  effects  from,  234 
castration  for,  310 
castration  for,  operative  technique 

of,  318 
cauterization  of,  273 
clinical  classification  of,  230 
colpo-hysterectomy  for,  273 
complicating  cancer  of  the  cervix,  389 
complicating  pregnancy,  327 
complicating  j>regnancy,  treatment 

of,  328 
compression  symptoms  from,  233 
connection  of,  with  the  uterine  tis- 
sue, 221 
connections  with  adjacent  organs, 

224 
course  of,  243 

cure  of,  after  castration,  324 
curetting  for  hemorrhage,  256 
cystic,  origin  of,  227 
degenerations  of,  225 
destruction  of,  through  the  vagina, 

273 
diagnosis  of,  232,  236 
encapsuled,  intra-peritoneal  euucle- 

ation  of,  281 
enucleation  of,  200 
enucleation  of,  accidents,  204 
enucleation  of,  mortality,  205 
enucleation  of,  trans- vaginal,  206 
etiology  of,  232,  245 


Fibroma,  gangrene  of,  228 

haemostatic  operations  for,  250 

hemorrhage,  cure  of,  after  castra- 
tion, 324 

incarcerated  in  the  pelvis,  treatment 
of,  250 

inflammation  of,  228 

influence  of,  on  menopause,  225 

intra-ligamentous,  241 

intra-ligamentous,  decortication  of, 
300 

intra-ligamentous,     surgical     treat- 
ment of,  300 

intra-uterine  scarification  in,  257 

medical  treatment  of,  247 

morcellation  of,  206 

morcellation  of,  mortality  of,  271 

of  abdominal  evolution,  239 

of  abdominal  evolution,  treatment 
of,  277 

of  the  cervix,  219 

of  the  metritic  type,  236 

of  the  subvaginal   portion    of   the 
uterus,  221 

of  vaginal  evolution,  237 

pedicled,  myomectomy  for,  280 

pelvic,  treatment  of,  300 

pelvic  variety,  221 

physical  signs,  235 

prognosis  of,  243 

pseudo-cysts  in,  220 

results  of  electrolysis  in,  253 

secondary  lesions  in,  229 

spontaneous  extrusion  of,  244 

structure  of,  222 

submucous,  of  the  fundus,  260 

suppuration  of,  228 

surgical  treatment  of,  257 

symptoms  of,  232 

treatment  by  electrolysis,  249 

treatment  by  ergot,  247 

treatment  by  hydrastis,  248 

uterine,  216 

vaginal  hysterectomy  for,  272 

with  multiple  nuclei,  treatment  of, 
283 
Fibro-sarcoma  of  the  fundus  uteri,  408 

diagnosis  of,  409 

etiology  of,  410 

pathology  of,  408 

symptoms  of,  409 
Fixation  forceps,  111 

of  the  uterus,  109 


574 


INDEX. 


Flexible  uterine  sounds,  107 
Follicular  hypertrophy  of  the  cervix,  152 
Folliculitis,  149 
Forceps,  dentated  cyst,  270 
fixation,  111 
for  elastic  ligature,  59 
Hegar's,  for  cauterization  after  cas- 
tration, 321 
Museux's,  197 

prehension,    for   vaginal    hysterec- 
tomy, 361 
Forcipressure,  61 
Foster's    experiments    in    cleaning   the 

hands,  1 
Foulis,  on  turpentine  for  cleaning  the 

hands,  2 
French  bed-pan,  8 

Freund's  operation  for  cancer  of  the  fun- 
dus, 412 
operation,  ligation  and  section  of  the 
broad  ligaments  in,  412 
Fritsch  on  cervical  amputation,  210 
Fundus  uteri,  cancer  of  the,  396 
diffuse  sarcoma  of  the,  406 
fixation  of  the,  in  retro-deviations, 
463 
Furbringer,    alcohol    for    cleaning   the 
hands,  2 

Gaxglia,  lymph,  in  cancer  of  the  uterus, 

342 
Gangrenous  metritis,  146 
Gastro-hysteropexy,    historical    review 
of,  460 

prognosis  of,  467 
Gauze  sponges  in  laparatomy,  21 
Gehrung's  pessary  for  cystocele,  496 
General  amesthesia  by  chloroform,  33 

by  ether,  33 
Genital  nerves  of  the  infant,  174 
Genital  prolapse,  480 

abdominal  hysteropexy  for,  512 

Alquie- Alexander  operation  for,  511 

Byford's  procedure  in,  514 

choice  of  treatment  for,  516 

colpo-perineorrhaphy  in,  498 

elytrorrhaphy  in,  497 

episiorrhaphy  in,  497 

etiology  of,  480 

Hegar's  operation  for,  498 

hysteropexy  for,  512 

Martin's  operation  for,  499,  501 

pathology  of,  481 


Genital  prolapse,  shortening  the  round 
ligaments  for,  511 

summary  of  the  treatment  of,  516 

surgical  treatment  of,  496 

therapeutic  indications  in,  515 

treatment  of,  493 

vaginal  hysterectomy  in,  515 

ventro-fixation  of  the  uterus  in,  512 
Genu-cubital  position,  91 
Genu-pectoral  position,  90 
Germont's  experiments  on  ligating  the 

ureters,  339 
Germs  in  the  female  genital  tract,  Stef- 
feck's  observations  on,  10 
Winter's  observations  on,  9 

in  the  lochia,  159 
Glandular  metritis,  142 
Glass  reel  for  silk  or  catgut,  27 
Gonorrhoeal    infection    in    the    female, 

Steinschneider,  158 
Goodell's  uterine  dilator,  115 
Granulations  of  the  cervix,  150 
Gynaecological  examination,  84 
Gynaecology,  anaesthesia  in,  31 

antisepsis  in,  1 

Hagedorist's  needles,  42 

Hands,  experiments  in  cleansing  the,  1 

Haemostasis,  40,  53 

curetting  in,  203 
Haemostatic  forceps,  Koeberl6's,  66 

suture  of  pelvic  floor,  362 

tamponade,  79 
Hegar's  dilators  for  the  uterus,  116 

forceps  for  cauterizing  the  pedicle 
after  oophorectomy,  321 
Hemorrhagic  metritis,  177,  202 
Hetero-infection  in  metritis,  159 
Hewitt's  cradle  pessary,  423 
History  of  bimanual  palpation,  97 
Horseshoe  catheter  for  intra-uterine  in- 
jections, Budin's,  15 
Hospital  bed-pan,  Baker's  pattern,  9 
Huguier's  conoidal  amputation  of  the 

cervix,  486 
Hypertrophy  of  the  cervix,  follicular,  152 
simple,  532 

in  genital  prolapse,  483 

of  the  uterus,  542 
Hypnotic  suggestion  as  local  anaesthetic, 

Hysterectomy,  mixed  method  of  sutur- 
ing the  pedicle  after,  295 


INDEX. 


0/0 


Hysterectomy  for  cancer,  operative  ac- 
cidents, 370 
French  statistics  of,  376 
for  cancer  of  the  cervix,  modified 
operations,  3G6 
mortality  after,  371 
survival  after,  374 
for  fibroma,  hsemostasis  in,  280 
indications  for,  279 
synonyms  of,  278 
in  cancer  of  the  fundus,  410 
para-sacral,  479 
tamponade  of  peritoneum  after, 

76 
through  the  sacrum,  381 
supra- vaginal,  for  fibroma,  283 

by  different  methods,  compara- 
tive results,  308 
causes  of  death  after,  305 
choice  of  method,  311 
drainage  after,  287 
dropped  elastic  ligature  in,  292 
extra  -  peritoneal    treatment   of 

pedicle,  288 
intra  -  peritoneal    treatment   of 

pedicle,  285 
ligation  of  the  ureter  during,  305 
mortality  of,  308 
operative  accidents  after,  303 
statistics  of,  308 
technique  of,  284 
total,  for  fibroma,  299 
vaginal,  for  cancer  of  the  fundus, 
statistics  of,  413 
for  cervical  cancer,  drainage  in, 

366 
for  fibroma,  272 
for  genital  prolapse,  515 
Schroder's  statistics  of,  377 
Verneuirs  statistics  of,  378 
Zuckerkandl's  method,  379 
Hysteropexy,  Czerny's  method,  465 
immediate  abdominal,  470 
in  retroversion,  indications  for,  468 
influence  of  pregnancy  on  the  uterns 

after,  467 
Kelly's  method  of,  470 
Leopold's  method  of,  464 
modifications  of,  470 
operative  technique  of,  463 
Pozzi's  method  of,  466 
prognosis  of,  467 
Terrier's  method  of,  465 


Hysterectomy,  ventral,  460 
Wylie's  method  of,  469 
Hysterorrhaphy  in  retro-deviations  (see 

Hysteropexy),  460 
Hysterotome,  Collin's,  432 
Hysterotomy,  278 

Immediate  progressive  dilatation,  115 
Indications  for  drainage,  71 
Infection  in  metritis,  159 

secondary,  from  silk  sutures,  40 
Infra-traction  of  the  uterus,  109 
Injections,  intra-uterine,  recurrent   ca- 
theters for,  14 

used  in  antisepsis  of  external  geni- 
tals, 4 

vaginal,  canulae  for,  8 

vaginal,  rules  for,  7 
Instruments,  construction  of,  2 

disinfection  of,  3 
Insufflator  for  iodoform,  13 
Interstitial  metritis,  141 
Intestinal  sutures,  45 
Intra-uterine  cauterization,  191 
Intra-uterine  drainage,  77 

injections,  14 

injections  in  fibroma,  256 

injections,  recurrent  catheters  for,  14 

irrigation  in  metritis,  189 

medication  in  metritis,  189 

touch, 111 
Intra-vaginal  amputation  of  the  cervix, 

354 
Inversion  of  the  uterus,  520 

of  the  uterus,  reduction  of,  526 
Iodoform    gauze,     Eiselsberg's    experi- 
ments on,  11 

insufflator,  13 
Irrigation,  continuous,  78 

continuous,  during  operations,  16 
Irrigator,  vaginal,  7 

Kelly's  ovariotomy  pad,  85 

perineal  pad,  85 
Knee-chest  position,  90 
Knee-elbow  position,  91 
Knot-tier,  Perrier's,  528 
Koeberld's  haemostatic  forceps,  66 
Kiichenmeister's  scissors,  117,  536 

Laceration  of  the  cervix.  154 
as  a  cause  of  metritis,  164 
complicating  erosion,  200 
jNbeggerath's  views  on,  164 


576 


INDEX. 


Laminaria  tents,  112 
Laparatomy.  assistants,  18 

antisepsis  in,  17 

care  of  peritoneum  in,  22 

gauze  sponges  for,  21 

preparation  of  patient  for,  18 

preparation  of  room  for,  19 

table  of  Mine.  Horn,  19 
Laplace's  experiments  with  bichloride 

solution,  6 
Latent  microbism  of  Verneuil,  161 
Latero-abdominal  position,  89 
Le  Fort's  method  of  closure  of  the  va- 
gina, 507 
Leg-holder,  Clover's,  87 

Ott's,  88 

Robb's,  90 
Lesions  of  chronic  metritis,  140 
Ligature,  elastic,  Hegar's  forceps  for,  59 
Ligation  in  mass,  methods  for,  55 
silk  for,  54 

of  inverted  uterus,  elastic,  528 

of  the  uterine  artery  in  uterine  dila- 
tation, 117 
in  Freund's  operation,  412 

preservation  of  materials  for,  24 
Local  anaesthesia  in  gynaecology,  31 
Lochia,  germs  in  the,  159 
Lourcine-Pascal,  operating-room  of,  5 
Lymphangiectatic  myoma,  266 

Malformations  of  the  cervix-,  533 
Mania  and  menstrual  disorders,  557 
Martin's  needle-holder,  44 
Massage  in  chronic  metritis,  205 
Materials  for  suture  and  ligation,  44 

preparation  of,  24 

preservation  of,  24 

for  tampons,  81 
Median  fixation,  direct,  in  retro-devia- 
tions, 463 
Membranous  dysmenorrhoea,  138,  179 
Menopause,  influence  of  the,  on  dysmen- 
orrhoea, 559 
Menorrhagia,  553 

etiology  of,  553 

general  causes  of,  553 

local  causes  of,  553 

pathology  of,  553 

symptoms  of,  552 

treatment  of,  .553 
Menstrual  disorders  and  epilepsy,  557 

neuroses,  557 


Menstruation,  absence  of,  547 

disorders  of,  547 

early  appearance  of,  547 

ectopic,  552 

influence  on,  of  removal  of  the  ova- 
ries, 549 

normal,  conditions  necessary  to,  549 

precocious,  547 

protracted,  547 

regularity  in,  conditions  of,  549 

tardy,  547 

uterine  mucous  membrane  during, 
135 

vicarious,  552 
Methods  of  dilating  the  uterus,  112 

of  gynaecological  examination,  84 

of  suture,  46 

of  suture  and  haemostasis,  40 
Metritis,  130 

acute,  134 

acute  septic,  137 

bacteria  in,  159 

castration  for,  212 

caustic  injections  in,  193 

cauterization  in,  191 

cervical  laceration    as   a   cause  of, 
164 

chronic,  137 

chronic,  amputation  of  the  cervix  in, 
205 

chronic  glandular,  142 

chronic  painful  form,  203 

classification  of,  131 

copulation,  excessive,  as  a  cause  of, 
162 

cough  in,  173 

course  of,  180 

diagnosis  of,  169,  180 

diathesis  as  a  cause  of,  166 

diphtheritic,  146 

drainage  in,  189 

dysmenorrhoea  in,  172 

dyspepsia  in,  172 

etiology  of,  162         i 

exanthemata  as  a  cause  of,  166 

gangrenous,  146 
.  general  condition  in,  175 

hemorrhagic,  202 

herpetic,  166 

hetero-infection  in,  159 

infection  in,  159 

interstitial,  141 

leucorrhoea  in,  170 


INDEX. 


577 


Metritis,  menstruation  as  a  cause  of,  162 

methods  of  examination  in,  176 

metrorrhagia  in,  172 

mineral  waters  for,  186 

of  the  cervix,  147 

pain  in,  169,  170 

parturition  as  a  cause  of,  163 

pathogeny  of,  157 

pathology  of,  133 

physical  signs  of,  175 

prognosis  of,  180 

reflex  symptoms  in,  172 

respiratory  reflexes  in,  173 

scrofulous,  106 

sweeping  and  curetting  in,  190 

symptoms  of,  169 

traumatism  as  a  cause  of,  165 

treatment  of,  184 

uterine  cough  in,  173 

uterine  leucorrhoea  in,  171 

vaginal  hysterectomy  for,  212 

vaginal  leucoi'rhoea  in,  170 
Meyer's  soft-rubber  pessary,  422 
Minor  haemostatic  operations  in  fibroma, 

256 
Mittelschmerz,  556 
Mixed  anaesthesia,  33 

advantages  of,  34 

history  of,  34 
Morcellation  of  fibromata,  266 
Mortality  of  castration  for  fibroma,  323 
Mounted  needles,  41 

Mucous  membrane  of  the  uterus,  power 
of  regeneration,  196 

polypi  of  the  cervix,  153 
Multivalve  specula,  102 
Museux's  forceps,  197 
Myoma,  lyinphangieetatic,  226 
Myomectomy,  277 

for  pedicled  fibroma,  280 

synopsis  of  published  results  of,  330 
Myomotomy,  vaginal,  266 

vaginal,  mortality  of,  271 

Naboth,  ovules  of,  149 
Narkalla's  method  of  exploring  the  ure- 
ter, 128 
Needle-holders,  40 
Needles,  40 

Hagedorn,  42 

mounted,  41 
Neuralgia  of  genital  origin,  173 
Neuroses  of  genital  origin,  173 
37 


Noeggerath  on  cervical  laceration,  164 
Normal  placenta,  136 

Obstructive  dysmenorrhea,  534 
Oliver's  catheter  for  intra-uterine  injec- 
tions, 14 
Oophoralgia,  557 
Oophorectomy  by  median  incision,  319 

treatment  of  the  pedicle  after,  320 
OOphoro-epilepsy,  557 
Oophoro-mania,  557 
Operating-room  of  the  Lourcine-Pascai,5 

surroundings  of,  3 
Operating-table,  Chad  wick's,  86 

Cleveland's,  88 
Operations  through   natural   passages, 
antisepsis  in,  1 

under  hypnosis  by  suggestion,  33 
Ovarian  dysmenorrhea,  555 
Ovariotomy,  chloroform  in,  36 

in  dysmenorrhea,  560 

pad,  Kelly's,  85 
Ovary,  cyst  of  the,  complicating  cervical 

cancer,  390 
Oven,  sterilizing,  Wiesnegg's,  26 
Ovules  of  Naboth,  149 

Palmer's  dilator,  115 
Palpation,  6 

abdominal,  91 

sources  of  error  in,  92 

bimanual,  history  of,  97 

Ullman's  modification  of,  100 

of  the  ureters,  120 
Para-sacral  hysterectomy,  379 
Passage  of  uterine  sound,  108 
Patient,  preparation  of,  for  laparatomy, 

18 
Pawlik's  method  of  catheterism  of  the 
ureters,  123 

ureteral  catheters,  125 

vaginal  folds,  125 

vesical  trigone,  124 
Payot's  abdominal  girdle,  422 
Pedicle,  continuous  fractional  ligature 
of  the,  after  hysterectomy,  294 

dressing  for  the,  291 

extirpation  of  the,  299 

extra-peritoneal  treatment  of  the,  288 

intra-peritoneal  treatment  of,  285 
Pelvic  colpo-hysteropexy,  458 
Perforation  of  the  uterus  with  the  cu- 
rette, 199 


578 


INDEX. 


Perrier's  knot -tier,  528 
Perineal  air  cushion,  494 

pad,  Kelly's,  85 
Perineauxesis,  499 

Perineoplasty,  Bischoff's  method,  503 
Perineorrhaphy,  statistics  of,  511 

supplementary  operations  in,. 504 
Peritoneal  absorption  of  bone,  etc.,  58 

cavity,  drainage  of,  69 

drainage,  tubes  for,  73 
Peritoneum,  care  of,  in  laparatomy,  22 

method  of  tamponing  the,  75 
Peritonitis  after  the  use  of  the  curette, 

199 
Permanent  uterine  dilatation,  118 
Pessary,  annular,  in  retroflexion,  444 

Borgnet's,  495 

cradle,  in  retro-deviation,  449 

cup-shaped,  494 

Fehling's,  431 

figure-of-eight,  449 

for    nullipara,    in   retro-deviations, 
449 

Fritsch's,  451 

Galabin's,  423 

Gehrung's,  496 

Hewitt's  cradle,  423 

Hodge's,  in  retroflexion,  444 

Landowskfs,  449 

Mund6's,  for  retroflexion,   446 

Roser-Scanzoni,  495 

Schultze's,  449 

Smith's,  in  retroflexion,  445 

Meyer's  soft-rubber,  422 

Thomas'  ante  version,  423 
Pessaries  for  ante  version,  421 

in  genital  prolapse,  493 

in  retroflexion,  445 

stem,  431 
Physical  signs  of  metritis,  175 
Placenta,  136 
Polypi,  complicating  pregnancy,  328 

"enormous,"  259 

mucous,  of  the  cervix,  153 

treatment  of,  258 
Polypous  metritis,  chronic,  143 
Portable  vaginal  irrigator,  7 
Portion  of  the  ureters  accessible  to  touch, 

121 
Position  of  patient  in  anaesthesia,  37 
Posterior  displacements,  434 
Pozzi's  elastic  ligator,  61 

enucleator,  262 


Pozzi's  method  of  sterilizing  water  for 
operations,  23 

needle-holder,  43 

tongue  forceps,  38 
Pregnancy  complicated  by  cancer  of  the 
cervix,  345,  388 

fibrous  tumors  complicating,  327 
Preparation  of   materials   for    ligation 

and  suture,  24 
Preservation  of  materials  for  ligation 

and  suture,  24 
Procidentia  of  genital  organs,  480 
Prognosis  of  metritis,  180 
Progressive  dilatation  of  the  uterus,  115 
Prolapse  of  the  genital  organs,  480 

acute,  490 

course  and  prognosis  of,  493 

physical  signs  of,  491 

resistance  to,  489 

suture  of  the  uterus  to  the  abdomi- 
nal wall  for,  512 

symptoms  of,  490 

treatment  of,  493 
Prolonged  anaesthesia,  effects  of,  35 
Pseudo-metritis,  131 
Puerperal  infection  in  metritis,  160 

Rapid  dilatation  of  the  cervix,  116 

Rectal  touch,  95 

Rectocele,  481 

Recurrent  catheters  for  intra-uterine  in- 
jection, 14 

Reduction  of  the  inverted  uterus,  grad- 
ual, 527 

Reels  for  silk  or  catgut,  27 

Reposition  of  the  uterus,  forcible,  526 

Retractor,  vaginal,  103 

Retro-deviations,  fixation  of  the  fundus 
in,  463 
hysteropexy  in,  462 
indhect  fixation  of  the  uterus  in,  463 
direct  lateral  fixation  in,  463 
direct  median  fixation  in,  463 
Nicoletis'  operation  for,  458 
suture  of  the  round  ligaments  in, 
453 

Retroflexion  of  the  uterus,  435 
choice  of  operation  for,  471 
pessaries  in,  445 
reduction  of,  440 

Retroversion  of  the  uterus,  434 

indications  for  hysteropexy  in,  469 

Ring  pessary,  Dumontpallier's,  422 


INDEX. 


579 


Rotary  atomizer,  Collin's,  20 
Round  ligaments  in  Alexander's  opera- 
tion, 45 
Rules  for  vaginal  injections,  7 

Salpingitis  in  posterior  displacements 

of  the  uterus,  438 
Sarcoma,  diffuse,  of  the  fundus  uteri,  398 
diagnosis  of,  407 
etiology  of,  407 
symptoms  of,  407 
diffuse,  of  the  uterine  mucous  mem- 
brane. 406 
fibrosum,  408 
Scarification,  intra-uterine,  in  fibroma, 

257 
Scarificators  for  the  cervix,  187 
Schultze's  method  in  reduction  of  retro- 
flexions, 442 
Scissors,  Kiichennieister's,  117 
Schroder's  operation  for  amputation  of 
the  cervix,  208 
operation,  compared  with  Emmet's, 
201 
Schticking's  operation  for  retro-devia- 
tions. 457 
Self-retaining  speculum,  Cleveland's,  105 
Semi-prone  position,  89 
Senile  atrophy  of  the  uterus,  540 
Septic  metritis,  acute,  137 
Sexual  life,  suspension  of  the,  547 
Silk  ligatures  and  sutures,  24 
Silkworm-gut,  28 
Silver  wire,  28 

Simon's  method  of  ureteral  catheterism, 
127 
speculum,  103 
Sims'  depressor,  105 
slide  applicator,  190 
speculum,  104 
Solid  caustics  in  metritis,  191 
Sounds,  uterine,  106 
Special   treatment   of   metritis  of   the 

various  forms,  186 
Speculum,  Brewer's,  102 
Cusco's,  102 
cylindrical.  101 
duck-bill,  102 
examination  by,  100 
for  vaginal  injections,  fenestrated,  8 
mult  i  valve,  102 
self-retaining,  Cleveland's,  105 
Simon's,  103 


Speculum,  Sims',  104 

types  of,  101 

univalve,  103 
Sponges  in  laparatomy,  21 
Steffeck,  observations  on  germs  in  the 

female  genital  tract,  10 
Steinschneider's  studies  on  the  seat  of 

gonorrheal  infection,  158 
Stenosis  of  the  cervix,  532 

electrolysis  in,  537 

sterility  from,  535 
Sterilizing  oven,  Wiesnegg's,  26 

water  for  operations,  Pozzi's  method, 
23 
Stillicidium  uteri,  557 
Stoltz's  operation  for  cystocele,  508 
Straus  and  Grermont,  experiments  of,  on 

ligating  the  ureters,  339 
Suggestion,  hypnotic,  as  local  anaesthet- 
ic, 32 
Supra-vaginal    amputation    of    gravid 

uterus,  330 
Surroundings  of  operating-room,  3 
Suture,  catgut,  25 

continuous,  in  layers,  49 

interrupted,  46 

intestinal,  45 

materials,  44 

materials,  absorption  of,  58 

methods  of,  40,  40 

mixed,  50 

preservation  of  materials  for,  24 

quilled,  52 

secondary  infection  of  silk,  46 

silk,  124 

silkworm-gut,  28 

silver-wire,  28 

simple  continued,  48 
Syndroma,  utei'ine,  169 

in  epithelioma  of  the  fundus,  402 

in  retroflexion,  438 

Tait's  cupping  glass  for  aspiration  of 

drainage  tube,  73 
Tampon,  materials  for,  81 

in  metritic  bleeding,  203 

in  metritis,  190 
Tamponade,  antiphlogistic,  80 

haemostatic,  79 

of  the  peritoneum    after  hysterec- 
tomy, 76 

of  the  vagina,  79 
Tents,  laminaria,  112 


580 


IXDEX. 


Tents,  tupelo.  113 
Terrillon"s  hysterorneter,  318 
Thomson's  experiments  with  suture  ma- 
terials, 58 

forceps,  68 
Tobacco-pouch  operation  for  cystocele, 

Stoltz's,  508 
Tongue  forceps,  38 
Touch,  intra- uterine,  111 

rectal,  95 

vaginal,  94 

vesical,  96 
Tubo-ovarian  vessels,  ligature  of,  in  cas- 
tration. 352 
Tumor  forceps,  Collin's,  259 
Tumors  incarcerated  in  the  pelvis,  treat- 
ment of,  256 
Tupelo  tents,  113 
Trachelorrhaphy,  209 
Transporting  patients,  carriage  for,  35 
Treatment  of  metritis,  184 
Tripier's  uterine  electrode,  252 
Types  of  speculum,  101. 

Ulceration  of  the  cervix,  150,  200 
Unilateral  castration,  323 
Univalve  speculum,  103 
Ureteral  catheters.  125 
Ureters,  c  a  t  h  e  t  e  r  i  s  m  of ,  Pavdik's 
method,  123 
exploration  of,  120 
exploration  of,  Xarkalla's  method. 

128 
exploration  of.  Pawlik's  method,  123 
ligation  of,  during  hysterectomy,  305 
ligation  of,  experiments  on,  339 
palpation  of  the,  120 
portion  of,  accessible  to  touch,  121 
Urethrocele  in  vaginal  prolapse,  493 
Uterine  artery,  ligation  of,  in  vaginal 
hysterectomy,  362 
ligation  of,  in  dilatation,  117 
atrophy,  diagnosis  of,  539 

removal  of  the  ovaries  a  cause 

of.  541 
symptoms  of,  539,  541 
treatment  of,  540 
atrophy,  acquired,  symptoms  of,  541 

treatment  of.  511,  541 
atrophy,  congenital,  symptoms  of, 

539 
cavity,  antisepsis  of,  12 
deviations,  diagnosis  of,  420 


Uterine  deviations,  historical  review,  418 
dilatation,  bilateral  division  of  the 
cervix  in,  117 

permanent,  118 
dilator,  115 

displacement,  symptoms  of,  420 
divulsion,  114 
dressing  forceps,  200 
dysmenorrhea,  556 
dyspepsia,  172 
fundus,  hysterectomy  in  cancer  of 

the,  410 
fibroma,  216 

fibroma,  varieties  of,  218 
electrodes,  251 
engorgement,  151,  178 
exploratory  incision,  119 
hypertrophy,  symptoms  of,  545 

treatment  of,  545 
infarction,  178 
inversion,  diagnosis  of,  522 

etiology  of,  520 

pathology  of,  520 

prognosis  of,  525 

symptoms  of.  522 

treatment  of,  525 
mucous  membrane  during  menstru. 

ation,  135 
parenchyma,  sarcoma  of  the,  408 
prolapse,  483 
sound  in  reduction  of  retroflexions, 

443 
sound,  rules  for  passing,  108 
sounds,  106 

flexible,  107 
supports,  elasticity  of  the,  489 
syndroma,  169 

in  uterine  deviations,  420 
Uterus,  acquired  atrophy  of  the,  540 
adenoma  of  the,  396 
after  hysteropexy,  influence  of  preg- 
nancy on,  467 
anterior  deviations  of  the,  419 
anterior  deviations  of  the,  pathol- 
ogy of,  419 
anterior  deviations  of  the,  treatment 

of,  421 
artifical  dilatation  of  the,  111 
cancer  of  the  body  of,  396 
carcinoma  of  the  body  of,  398 
diagnosis  of  inversion  of  the,  524 
displacements  of  the,  416 
displacement  of  the,  upward,  473 


IXDEX. 


581 


Utei'us,  elastic  ligation  for  inverted,  528 
epithelioma  of,  400 
forcible  reposition  of  the,  526 
fixation  of,  109 

after  reposition,  445 
forward  deviations  of  the,  419 
gradual  reduction  of  the  inverted, 

527 
gravid,  myomectomy  on  the,  330 
gravid,  supra-vaginal  amputation  of, 

for  fibroma,  330 
hypertrophy  of  the,  542 
hypoplasia  of  the,  539 
immediate  progressive  dilatation  of 

the.  115 
infra-traction  of,  109 
inversion  of  the.  520 
inverted,  ligature-holder  for  removal 

of  the.  529 
posterior  displacements  of  the,  434 
prolapse  of.  483 
pubescens,  539 
retroflexion  of  the,  435 
retroversion  of  the,  434 
sarcoma  of  the  body  of,  398 
senile  atrophy  of,  540 
subinvolution   of  the.   in  posterior 

displacements,  436 
symptoms  of  deviations  of,  420 
symptoms  of  inversion  of  the,  524 
ventro-fixation  of,  512 

Vagina,  closure  of  the,  by  Le  Fort's 
method.  507 

operations  through,  antisepsis  in,  1 

tamponade  of  the.  79 
Vaginal  folds.  PaTvlik*s,  125 


Vaginal  hysterectomy  in  cancer  of  the 
cervix,  360 

hysterectomy  for  metritis,  212 

hysterectomy    for   retro-deviations, 
456 

hysterectomy,    prehension    forceps 
for,  361 

injections,  canulte  for,  8 

injections  in  metritis,  204 

injections,  rules  for,  7 

portable  irrigator,  7 

irrigator  for  suspension,  7 

prolapse,  481 

retractor,  103 

touch,  94 
Ventro-fixation  in  retro-deviations,  460 
Verneuil's  latent  microbism,  161 

method  of  intra- vaginal  amputation 
of  the  cervix,  354 
Vesical  touch,  96 

trigone,  Pavdik,  124 
Vicarious  menstruation,  552 
Von  Hacker's  crayons,  13 

Water  for  operations,  Pozzi's  method 

of  sterilizing,  23 
Wiesnegg's  sterilizing  oven,  26 
Winter,  observations  on  germs  in  female 
genital  tract,  9 
studies  on  bacteria  in  the  uterus,  160 
Wolfler's  forceps,  72 

experiments  with  cocaine  in  local 
anaesthesia,  31 
Wounded  surfaces,  cauterization  of,  24 
Wounds,  drainage  of,  68 

Zinc  chloride  for  cervical  ulceration,  200 
Zuckerkandl's  hysterectomy,  379, 


m+'iMBk 


.A*    * 


;  '  *v—  ■•• 

1    .  ^    ' 

"■or  * 

T  &   •* ... 

DUE  DATE 


DEC 


201-6503 


'm% 


EC  27  1993 


-■g!9?7    JJARP4  19)7 


Printed 
in  USA 


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